Provider Demographics
NPI:1679509509
Name:MOFFA, FREDERICK ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:ALLEN
Last Name:MOFFA
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 1:20 COPPER HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06035-1524
Mailing Address - Country:US
Mailing Address - Phone:860-653-7440
Mailing Address - Fax:860-653-7469
Practice Address - Street 1:355 SALMON BROOK ST
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06035-1804
Practice Address - Country:US
Practice Address - Phone:860-653-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090002388CT 04OtherBLUE CROSS BLUE SHIELD
CT004172699Medicaid