Provider Demographics
NPI:1568411007
Name:MOFFETT, COLIN LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:LEE
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1900
Mailing Address - Fax:
Practice Address - Street 1:111 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4317
Practice Address - Country:US
Practice Address - Phone:704-874-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-1384996OtherTAX ID
NC8908125Medicaid
NC08125OtherBCBS
NCT64031Medicare UPIN
NC1568411007Medicare NSC