Provider Demographics
NPI:1003858465
Name:MOFFETT, DARRYL G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:G
Last Name:MOFFETT
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3544 E 17TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6911
Mailing Address - Country:US
Mailing Address - Phone:208-535-4900
Mailing Address - Fax:208-535-4906
Practice Address - Street 1:3544 E 17TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6911
Practice Address - Country:US
Practice Address - Phone:208-535-4900
Practice Address - Fax:208-535-4906
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2015-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM-6263207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002726100Medicaid
IDE91684Medicare UPIN
ID1107241Medicare ID - Type Unspecified