Basic Information
| Provider Information | |||||||||
| NPI: | 1144228057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSES | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730700550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053647900 | ||||||||
| FaxNumber: | 4053666214 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 E ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053647900 | ||||||||
| FaxNumber: | 4053666214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 23214 | OK | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0195480001 | 01 | OK | PALMETTO | OTHER | P00049091 | 01 | OK | RR MEDICARE | OTHER | 7689494 | 01 | OK | AETNA | OTHER |