Provider Demographics
NPI:1801950126
Name:MOSHER, CHARLES B JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:MOSHER
Suffix:JR
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:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0155
Mailing Address - Country:US
Mailing Address - Phone:209-966-3672
Mailing Address - Fax:209-966-5548
Practice Address - Street 1:5300 HWY 49 N
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-0155
Practice Address - Country:US
Practice Address - Phone:209-966-3672
Practice Address - Fax:209-966-5548
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20790208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G207900Medicaid
CAA41074Medicare UPIN
CA00G207900Medicaid