Provider Demographics
NPI:1023650231
Name:MOSES, TONY
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:MOSES
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 1:4650 DAWN CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-6655
Mailing Address - Country:US
Mailing Address - Phone:706-604-2901
Mailing Address - Fax:
Practice Address - Street 1:4650 DAWN CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-6655
Practice Address - Country:US
Practice Address - Phone:706-604-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049482255Medicaid