Provider Demographics
NPI:1801903638
Name:MOSS, EDWIN BURNETT (OD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BURNETT
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 1:800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3349
Mailing Address - Country:US
Mailing Address - Phone:318-377-2020
Mailing Address - Fax:318-377-9833
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3349
Practice Address - Country:US
Practice Address - Phone:318-377-2020
Practice Address - Fax:318-377-9833
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA918096T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1363871Medicaid
LAT19485Medicare UPIN
LA47960Medicare ID - Type Unspecified