Provider Demographics
NPI:1568463909
Name:MOISA, IDEL I (MD)
Entity Type:Individual
Prefix:
First Name:IDEL
Middle Name:I
Last Name:MOISA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SCHOOL ST
Mailing Address - Street 2:STE 304
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2548
Mailing Address - Country:US
Mailing Address - Phone:516-671-0085
Mailing Address - Fax:516-671-0272
Practice Address - Street 1:3 SCHOOL ST
Practice Address - Street 2:STE 304
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2548
Practice Address - Country:US
Practice Address - Phone:516-671-0085
Practice Address - Fax:516-671-0272
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-03-03
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NY161323-1207Y00000X, 207YP0228X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
A61864Medicare UPIN
NY28E811Medicare PIN