Provider Demographics
NPI:1962405126
Name:MOSS, MARILYN CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:CAROL
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2100 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8110
Mailing Address - Country:US
Mailing Address - Phone:321-752-7100
Mailing Address - Fax:321-752-7105
Practice Address - Street 1:2100 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8110
Practice Address - Country:US
Practice Address - Phone:321-752-7100
Practice Address - Fax:321-752-7105
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME22466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064147200Medicaid
D53776Medicare UPIN
FL064147200Medicaid