Provider Demographics
NPI:1750461935
Name:MOFFETT, MILTON RENWICK (RDO)
Entity Type:Individual
Prefix:MR
First Name:MILTON
Middle Name:RENWICK
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ASHBY RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-2217
Mailing Address - Country:US
Mailing Address - Phone:781-275-0736
Mailing Address - Fax:
Practice Address - Street 1:90 LEONARD ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-2519
Practice Address - Country:US
Practice Address - Phone:617-484-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1286156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0581460001Medicaid
MA0581460001Medicare NSC