Provider Demographics
NPI:1396799565
Name:MOSS, VINCENT LAVAUGHN (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:LAVAUGHN
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 1:98 JAMES STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820
Mailing Address - Country:US
Mailing Address - Phone:732-548-1000
Mailing Address - Fax:732-548-7590
Practice Address - Street 1:98 JAMES ST 202
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3902
Practice Address - Country:US
Practice Address - Phone:732-548-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4286662086S0127X
NJ25MA080027002086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ107284V2QMedicare PIN
I34832Medicare UPIN