Provider Demographics
NPI:1982657235
Name:MOSS, FRED R (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:R
Last Name:MOSS
Suffix:
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 1:3233 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3934
Mailing Address - Country:US
Mailing Address - Phone:513-419-9367
Mailing Address - Fax:
Practice Address - Street 1:121 STANFORD CT
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5657
Practice Address - Country:US
Practice Address - Phone:916-671-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010977582084P0800X
IL0361292702084P0800X
OH35059484A2084P0800X
CAG890832084P0800X
IN01059042A2084P0800X
NC2012021162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200467160AMedicaid
OH0827672Medicaid
KY6493173600Medicaid
KY6493173600Medicaid
E76759Medicare UPIN