Provider Demographics
NPI:1013195577
Name:WALTER S MOZDEN LO
Entity Type:Organization
Organization Name:WALTER S MOZDEN LO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOZDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-889-9887
Mailing Address - Street 1:7 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2915
Mailing Address - Country:US
Mailing Address - Phone:860-889-9887
Mailing Address - Fax:
Practice Address - Street 1:7 CLINIC DR
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2915
Practice Address - Country:US
Practice Address - Phone:860-889-9887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001299332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT100000818CT02OtherLUMENOS
CT19796OtherSPECTERA
CT0187430001OtherMEDICARE
CT100000818CT02OtherBC/BS