Provider Demographics
NPI:1255441382
Name:MOSS, LUCIEN KENNEDY JR (MD)
Entity type:Individual
Prefix:DR
First Name:LUCIEN
Middle Name:KENNEDY
Last Name:MOSS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 3RD AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8994
Mailing Address - Country:US
Mailing Address - Phone:337-494-4868
Mailing Address - Fax:337-494-4870
Practice Address - Street 1:2770 3RD AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-494-4868
Practice Address - Fax:337-494-4870
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015821174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1341280Medicaid
LA50046C963OtherMEDICARE LEGACY
LA1341280Medicaid
LA50046Medicare ID - Type Unspecified