1558352112 NPI number — DR. SUSAN G MOSTER D.O.

Table of content: DR. SUSAN G MOSTER D.O. (NPI 1558352112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558352112 NPI number — DR. SUSAN G MOSTER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSTER
Provider First Name:
SUSAN
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558352112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75235-0629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-424-2200
Provider Business Mailing Address Fax Number:
214-231-2159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 W MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-8517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-870-7300
Provider Business Practice Location Address Fax Number:
817-335-9529
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  H2624 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113878602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113878602 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8GF863 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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