Provider Demographics
NPI:1689625188
Name:MOSS, JEREMY ETHAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ETHAN
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4639 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1838
Mailing Address - Country:US
Mailing Address - Phone:203-374-5546
Mailing Address - Fax:203-371-4056
Practice Address - Street 1:4639 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1838
Practice Address - Country:US
Practice Address - Phone:203-374-5546
Practice Address - Fax:203-371-4056
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043137207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI35817Medicare UPIN