Provider Demographics
NPI:1609869353
Name:MOSS, MELISSA K (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:K
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S 10TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:802 S 10TH ST STE C
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4662
Practice Address - Country:US
Practice Address - Phone:337-238-4189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490067Medicaid
LA1490067Medicaid
G89485Medicare UPIN