Provider Demographics
NPI:1720166523
Name:MOSS, SANDRA DOTSON (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DOTSON
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 OLD JACKSON HWY 31E
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141
Mailing Address - Country:US
Mailing Address - Phone:270-678-5740
Mailing Address - Fax:270-678-4701
Practice Address - Street 1:290 OLD JACKSON HWY 31E
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141
Practice Address - Country:US
Practice Address - Phone:270-678-5740
Practice Address - Fax:270-678-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64198765Medicaid
KY000000045939OtherBCBS INDIVIDUAL NUMBER
KYF26044Medicare UPIN