Provider Demographics
NPI:1003073214
Name:MICHAEL D MOZZETTI MD PL
Entity Type:Organization
Organization Name:MICHAEL D MOZZETTI MD PL
Other - Org Name:EXPRESS CARE MEDICAL CINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DOMINIC
Authorized Official - Last Name:MOZZETTI
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD, PL
Authorized Official - Phone:941-629-1218
Mailing Address - Street 1:3161 HARBOR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6754
Mailing Address - Country:US
Mailing Address - Phone:941-629-1218
Mailing Address - Fax:941-625-9465
Practice Address - Street 1:3161 HARBOR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6754
Practice Address - Country:US
Practice Address - Phone:941-629-1218
Practice Address - Fax:941-625-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME069032207Q00000X
FLME69032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32306OtherBLUE CROSS BLUE SHIELD
FL1867775OtherAETNA
FL262587296OtherHUMANA
FL262587296OtherBCBS FLORIDA
FL262587296OtherCIGNA
FL262587296OtherCIGNA
FL262587296OtherHUMANA
FLAJ709Medicare PIN