Basic Information
| Provider Information | |||||||||
| NPI: | 1891109633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSELLEN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631662 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452631662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593442079 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 7730 MONTGOMERY RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452364283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137915999 | ||||||||
| FaxNumber: | 5137914567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6303 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0131965 | 05 | OH | MEDICAID | 7100376230 | 05 | KY | MEDICAID |