Provider Demographics
NPI:1639162498
Name:MOSHER, MITCHELL RONALD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:RONALD
Last Name:MOSHER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 SMITH LN
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4103
Mailing Address - Country:US
Mailing Address - Phone:916-783-0496
Mailing Address - Fax:916-783-9406
Practice Address - Street 1:1133 SMITH LN
Practice Address - Street 2:SUITE 5
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4103
Practice Address - Country:US
Practice Address - Phone:916-783-0496
Practice Address - Fax:916-783-9406
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1359213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10914Medicare UPIN
CA000E13590Medicare ID - Type Unspecified