Provider Demographics
NPI:1639122252
Name:MOSS, PAT L (OD)
Entity type:Individual
Prefix:DR
First Name:PAT
Middle Name:L
Last Name:MOSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-1107
Mailing Address - Country:US
Mailing Address - Phone:812-738-2278
Mailing Address - Fax:812-738-1167
Practice Address - Street 1:215 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112
Practice Address - Country:US
Practice Address - Phone:812-738-2278
Practice Address - Fax:812-738-1167
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001563A152W00000X
IN18001563B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000076009OtherBCBS PIN
IN410002883OtherRR MEDICARE PIN
IN100153090AMedicaid
IN000000076009OtherBCBS PIN
IN100153090AMedicaid
IN410002883OtherRR MEDICARE PIN