Provider Demographics
NPI:1417037730
Name:MOOTZ, JEFFREY SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:MOOTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 VALLEY GREEN SQUARE
Mailing Address - Street 2:
Mailing Address - City:LE SUEUR
Mailing Address - State:MN
Mailing Address - Zip Code:56058
Mailing Address - Country:US
Mailing Address - Phone:507-665-3366
Mailing Address - Fax:507-665-3990
Practice Address - Street 1:303 VALLEY GREEN SQUARE
Practice Address - Street 2:
Practice Address - City:LE SUEUR
Practice Address - State:MN
Practice Address - Zip Code:56058
Practice Address - Country:US
Practice Address - Phone:507-665-3366
Practice Address - Fax:507-665-3990
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC08356Medicare ID - Type Unspecified
T65887Medicare UPIN