Provider Demographics
NPI:1083677793
Name:MOFFITT, SUZELLE L (MD)
Entity Type:Individual
Prefix:
First Name:SUZELLE
Middle Name:L
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 HILL COUNTRY DR
Mailing Address - Street 2:STE 101
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6024
Mailing Address - Country:US
Mailing Address - Phone:830-258-7090
Mailing Address - Fax:830-258-7098
Practice Address - Street 1:121 EL PASO RD
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6033
Practice Address - Country:US
Practice Address - Phone:575-630-8350
Practice Address - Fax:575-257-4055
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5566207Q00000X
NMMD2017-0489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21107831Medicaid
TX8GA072OtherBCBS PROVIDER ID NUMBER
NM21107831Medicaid
TX355300YL21Medicare PIN