Provider Demographics
NPI:1710418546
Name:MOSS, MATTHEW C (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:501 MARSHALL ST STE 301
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1687
Mailing Address - Country:US
Mailing Address - Phone:013-539-9006
Mailing Address - Fax:601-353-3654
Practice Address - Street 1:501 MARSHALL ST STE 301
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1687
Practice Address - Country:US
Practice Address - Phone:601-353-9900
Practice Address - Fax:601-353-3654
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS29978208800000X
MS39978208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06152598Medicaid