Provider Demographics
NPI:1245760065
Name:EGE MOIRA, FOTOCK
Entity Type:Individual
Prefix:MRS
First Name:FOTOCK
Middle Name:
Last Name:EGE MOIRA
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 1:8309 CARROLLTON PKWY
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3404
Mailing Address - Country:US
Mailing Address - Phone:202-766-0743
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVE NW STE LL16
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1328
Practice Address - Country:US
Practice Address - Phone:202-723-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide