Provider Demographics
NPI:1972691202
Name:MOSER, DALE J
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:J
Last Name:MOSER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 B N MCEWAN ST.
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1116
Mailing Address - Country:US
Mailing Address - Phone:989-386-2020
Mailing Address - Fax:989-386-7308
Practice Address - Street 1:1520 B N MCEWAN ST.
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1116
Practice Address - Country:US
Practice Address - Phone:989-386-2020
Practice Address - Fax:989-386-7308
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1972691202Medicaid
410008233OtherRAIL ROAD MEDICARE
MI0A80041OtherBLUECROSS AND BLUE SHIELD OF MICHIGAN
MI0A80041OtherBLUECROSS AND BLUE SHIELD OF MICHIGAN
MI1972691202Medicaid