Provider Demographics
NPI:1215055207
Name:MOSS, CHARLES ALLEN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLEN
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8950 VILLA LA JOLLA DRIVE
Mailing Address - Street 2:A217
Mailing Address - City:LA JOLLAA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1711
Mailing Address - Country:US
Mailing Address - Phone:858-457-1314
Mailing Address - Fax:858-457-3615
Practice Address - Street 1:8950 VILLA LA JOLLA DRIVE
Practice Address - Street 2:A217
Practice Address - City:LA JOLLAA
Practice Address - State:CA
Practice Address - Zip Code:92037-1711
Practice Address - Country:US
Practice Address - Phone:858-457-1314
Practice Address - Fax:858-457-3615
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CAG033632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45618Medicare UPIN