Provider Demographics
NPI:1619047768
Name:MOSER, THOMAS L (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:MOSER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S P ST
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46036-3333
Mailing Address - Country:US
Mailing Address - Phone:765-552-7376
Mailing Address - Fax:765-552-7377
Practice Address - Street 1:1900 S P ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-3333
Practice Address - Country:US
Practice Address - Phone:765-552-7376
Practice Address - Fax:765-552-7377
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001779B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100170930AMedicaid
IN100170930AMedicaid
INT 34889Medicare UPIN
IN504230Medicare PIN