Provider Demographics
NPI:1003804386
Name:MOFFAT, DOUGLAS HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HOWARD
Last Name:MOFFAT
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 1:245 E PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5304
Mailing Address - Country:US
Mailing Address - Phone:716-646-1233
Mailing Address - Fax:716-882-4426
Practice Address - Street 1:360 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1205
Practice Address - Country:US
Practice Address - Phone:716-882-4900
Practice Address - Fax:416-882-4426
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00708338Medicaid
NY14238NMedicare ID - Type Unspecified
NY00708338Medicaid