Provider Demographics
NPI:1689120016
Name:MOFFITT, THOMAS S (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:IM, DWIGHT D EISENHOWER ARMY MEDICAL CENTER
Practice Address - Street 2:300 EAST HOSPITAL ROAD
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA080627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program