Provider Demographics
NPI:1104041342
Name:MOCCIA, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:MOCCIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-549-0815
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2C
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-549-0815
Practice Address - Fax:321-768-0039
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1206562086S0129X, 2086S0129X
SC296862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014565100Medicaid
FLHY966ZOtherMEDICARE HF
SCAA18367895Medicare PIN
SC296860Medicaid