Provider Demographics
NPI:1689674145
Name:MOSIMAN, CORWYN ALFRED (OD)
Entity Type:Individual
Prefix:DR
First Name:CORWYN
Middle Name:ALFRED
Last Name:MOSIMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:386 S GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3099
Mailing Address - Country:US
Mailing Address - Phone:831-724-1063
Mailing Address - Fax:831-724-1067
Practice Address - Street 1:386 S GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3099
Practice Address - Country:US
Practice Address - Phone:831-724-1063
Practice Address - Fax:831-724-1067
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7532 TPA152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396787214OtherGROUP NPI
CA770194563Medicare UPIN
CA204977941Medicare UPIN
CAEK0062Medicare PIN