Provider Demographics
NPI:1336788942
Name:MOSS, TIMOTHY (ABOC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 ABBOTT AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1415
Mailing Address - Country:US
Mailing Address - Phone:713-591-7781
Mailing Address - Fax:
Practice Address - Street 1:1568 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2639
Practice Address - Country:US
Practice Address - Phone:414-221-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician