Provider Demographics
NPI:1134170285
Name:MOSS, MORTON (MD)
Entity type:Individual
Prefix:
First Name:MORTON
Middle Name:
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 1:1208 OLD STABLE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-2419
Mailing Address - Country:US
Mailing Address - Phone:703-356-7824
Mailing Address - Fax:703-442-0992
Practice Address - Street 1:1208 OLD STABLE RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-2419
Practice Address - Country:US
Practice Address - Phone:703-356-7824
Practice Address - Fax:703-442-0992
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-027459174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
300002472Medicare PIN
D05867Medicare UPIN
006299W85Medicare ID - Type UnspecifiedMC INDIVIDUAL PROVIDER #