Provider Demographics
NPI:1942259171
Name:MOSES, GIOVANNA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:GIOVANNA
Middle Name:MARIE
Last Name:MOSES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 PHOENIX ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2340
Mailing Address - Country:US
Mailing Address - Phone:262-728-2667
Mailing Address - Fax:262-728-3539
Practice Address - Street 1:1221 PHOENIX ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2340
Practice Address - Country:US
Practice Address - Phone:262-728-2667
Practice Address - Fax:262-728-3539
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2918-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38629100Medicaid
WI000247318Medicare ID - Type Unspecified
WI38629100Medicaid