Provider Demographics
NPI:1659304871
Name:MOSS, ROBERT LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LESLIE
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 1:114 BUSINESS CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136
Mailing Address - Country:US
Mailing Address - Phone:410-833-2772
Mailing Address - Fax:410-526-4897
Practice Address - Street 1:114 BUSINESS CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136
Practice Address - Country:US
Practice Address - Phone:410-833-2772
Practice Address - Fax:410-526-4897
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032882207RG0300X, 207R00000X
MDD32882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD75792OtherAETNA
MD405231500Medicaid
MDKF68 / 351268-01OtherBC/BS OF MD
MDS190 / 0017OtherBLUE CHOICE
MDS190 / 0017OtherBLUE CHOICE
MDN101-1Medicare PIN
MD405231500Medicaid