Provider Demographics
NPI:1548455561
Name:GARY M. MOSS, O.D.
Entity type:Organization
Organization Name:GARY M. MOSS, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-483-2100
Mailing Address - Street 1:1769 WASHTENAW RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2020
Mailing Address - Country:US
Mailing Address - Phone:734-483-2100
Mailing Address - Fax:734-483-2060
Practice Address - Street 1:1769 WASHTENAW RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2020
Practice Address - Country:US
Practice Address - Phone:734-483-2100
Practice Address - Fax:734-483-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002648332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5069375Medicaid
MI0931160001OtherSUPPLIER
MIU31668Medicare UPIN
MI0931160001Medicare NSC
MI0M96060Medicare PIN