Provider Demographics
NPI:1740289677
Name:MOSS, GARY (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
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 1:1255 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3468
Mailing Address - Country:US
Mailing Address - Phone:617-262-2020
Mailing Address - Fax:617-236-6323
Practice Address - Street 1:1255 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3468
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:617-236-6323
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA354023Medicaid
MAW17253Medicare ID - Type Unspecified
MA354023Medicaid