Provider Demographics
NPI:1407498942
Name:MOFFIT, TERRY LEE
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:MOFFIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1811
Mailing Address - Country:US
Mailing Address - Phone:909-521-6876
Mailing Address - Fax:909-495-1782
Practice Address - Street 1:1165 W 15TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1811
Practice Address - Country:US
Practice Address - Phone:909-521-6876
Practice Address - Fax:909-495-1782
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679524391Medicaid