Provider Demographics
NPI:1013206481
Name:MOSS AND MAIOCCO MD LLC
Entity Type:Organization
Organization Name:MOSS AND MAIOCCO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:MAIOCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-374-5130
Mailing Address - Street 1:4639 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1832
Mailing Address - Country:US
Mailing Address - Phone:203-374-5546
Mailing Address - Fax:203-371-4056
Practice Address - Street 1:4639 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1832
Practice Address - Country:US
Practice Address - Phone:203-374-5546
Practice Address - Fax:203-371-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4191491Medicaid
070000152Medicare PIN
CT4191491Medicaid