Provider Demographics
NPI:1043585110
Name:MOYA TAPIA, MANUEL ALFREDO (MD)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:ALFREDO
Last Name:MOYA TAPIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MANUEL
Other - Middle Name:ALFREDO
Other - Last Name:MOYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:630 W 168TH ST # 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-304-5493
Mailing Address - Fax:212-305-3035
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-304-5493
Practice Address - Fax:212-305-3035
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53680207R00000X
NY303745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT53680OtherLICENSE