Provider Demographics
NPI:1174798060
Name:MOFFAT, MITCHELL GENE (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:GENE
Last Name:MOFFAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MITCHELL
Other - Middle Name:GENE
Other - Last Name:MOFFAT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:546 CROMWELL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1898
Mailing Address - Country:US
Mailing Address - Phone:860-757-3874
Mailing Address - Fax:860-757-3875
Practice Address - Street 1:546 CROMWELL AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1898
Practice Address - Country:US
Practice Address - Phone:860-757-3874
Practice Address - Fax:860-757-3875
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031530207P00000X, 207QA0401X, 208M00000X, 207Q00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA51364Medicare UPIN