Provider Demographics
NPI:1588665137
Name:MOSS, GARY BLAIR (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:BLAIR
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 SIR WILLIAM OSLER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3003
Mailing Address - Country:US
Mailing Address - Phone:757-481-4383
Mailing Address - Fax:757-481-4611
Practice Address - Street 1:1704 SIR WILLIAM OSLER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3003
Practice Address - Country:US
Practice Address - Phone:757-481-4383
Practice Address - Fax:757-481-4611
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049940207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588665137OtherINDIVIDUAL NPI#
VA56572OtherOPTIMA/SENTARA
CF1969OtherRAILROAD MEDICARE GROUP #
1326022880OtherGROUP NPI#
VA322700OtherANTHEM
VA5803071Medicaid
VA348140OtherMAMSI
VAC01592OtherMEDICARE GROUP #
VAC01592OtherMEDICARE GROUP #
VA56572OtherOPTIMA/SENTARA
VA110006817Medicare PIN