Provider Demographics
NPI:1912906819
Name:MOSELEY, BRAD L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:L
Last Name:MOSELEY
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 1:795 TRAMWAY LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1606
Mailing Address - Country:US
Mailing Address - Phone:505-314-3696
Mailing Address - Fax:
Practice Address - Street 1:795 TRAMWAY LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1606
Practice Address - Country:US
Practice Address - Phone:505-314-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000167451207Q00000X
NM91-272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO80167881OtherRAILROAD MEDICARE
MO205125107Medicaid
MO80167881OtherRAILROAD MEDICARE
MO001013557Medicare PIN