Provider Demographics
NPI:1790772374
Name:MOSELEY, CLAIBORNE LAKE III (MD)
Entity Type:Individual
Prefix:
First Name:CLAIBORNE
Middle Name:LAKE
Last Name:MOSELEY
Suffix:III
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 1:300 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3104
Mailing Address - Country:US
Mailing Address - Phone:870-935-0519
Mailing Address - Fax:870-802-0355
Practice Address - Street 1:300 CARSON ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3104
Practice Address - Country:US
Practice Address - Phone:870-935-0519
Practice Address - Fax:870-802-0355
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8222207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121550001Medicaid
ARF03007Medicare UPIN
AR121550001Medicaid