Provider Demographics
NPI:1417069931
Name:MOELLER, LAVINIA PAIGE (DO)
Entity Type:Individual
Prefix:DR
First Name:LAVINIA
Middle Name:PAIGE
Last Name:MOELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 KNOLL TERRACE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7307
Mailing Address - Country:US
Mailing Address - Phone:973-575-4339
Mailing Address - Fax:973-575-5725
Practice Address - Street 1:323 BELLEVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-429-1010
Practice Address - Fax:973-429-1199
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB69110208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8289701Medicaid
NJ041313Medicare ID - Type Unspecified
H23097Medicare UPIN