Provider Demographics
NPI:1295155042
Name:MOSES, LARRY (MED)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-3618
Mailing Address - Country:US
Mailing Address - Phone:918-623-9218
Mailing Address - Fax:918-623-9218
Practice Address - Street 1:310 S 10TH ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-3618
Practice Address - Country:US
Practice Address - Phone:918-623-9218
Practice Address - Fax:918-623-9218
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator