Provider Demographics
NPI:1154473254
Name:MOSELEY, KRISTI B (OD)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:B
Last Name:MOSELEY
Suffix:
Gender:F
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:PO BOX 983
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73802-0983
Mailing Address - Country:US
Mailing Address - Phone:580-254-5060
Mailing Address - Fax:580-256-1100
Practice Address - Street 1:1602 9TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-4610
Practice Address - Country:US
Practice Address - Phone:580-254-5060
Practice Address - Fax:580-256-1100
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763350AMedicaid
OK1193390001Medicare NSC
OK100763350AMedicaid