Provider Demographics
NPI:1700996659
Name:MOSS, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4150 NELSON RD STE G
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4133
Practice Address - Country:US
Practice Address - Phone:337-562-3732
Practice Address - Fax:337-562-3699
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.019356208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5R705C963OtherMEDICARE LEGACY
LA1967360Medicaid
LAF59076Medicare UPIN
LA5R705Medicare ID - Type Unspecified