Provider Demographics
NPI:1114543105
Name:MOYA SMITH, TLALLIAZTLAN E
Entity Type:Individual
Prefix:
First Name:TLALLIAZTLAN
Middle Name:E
Last Name:MOYA SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2884
Mailing Address - Country:US
Mailing Address - Phone:978-686-0090
Mailing Address - Fax:
Practice Address - Street 1:34 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2884
Practice Address - Country:US
Practice Address - Phone:978-686-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAETLL-1096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine