Provider Demographics
NPI:1467584102
Name:MOFFETT, STEPHEN JOSEPH (OD APC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:OD APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 8TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2189
Mailing Address - Country:US
Mailing Address - Phone:619-435-6221
Mailing Address - Fax:619-435-6289
Practice Address - Street 1:1010 8TH ST STE B
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2189
Practice Address - Country:US
Practice Address - Phone:619-435-6221
Practice Address - Fax:619-435-6289
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11550T152W00000X
NV0388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16419Medicare PIN
CAU84279Medicare UPIN
CAWOP11550AMedicare PIN