Provider Demographics
NPI:1871534933
Name:MOSS, JONATHAN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:MOSS
Suffix:
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 1:100 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:VA
Mailing Address - Zip Code:22812-9511
Mailing Address - Country:US
Mailing Address - Phone:540-828-2634
Mailing Address - Fax:540-828-6911
Practice Address - Street 1:100 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812
Practice Address - Country:US
Practice Address - Phone:540-828-2634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0075192207Q00000X
VA0101042395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080002665Medicare PIN
VAMC12839Medicare PIN