Provider Demographics
NPI:1790852903
Name:MOFFRE, DOMINICK PETER (DO)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:PETER
Last Name:MOFFRE
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 1:65 BRINKER DR
Mailing Address - Street 2:RO #1
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144
Mailing Address - Country:US
Mailing Address - Phone:518-286-3004
Mailing Address - Fax:
Practice Address - Street 1:65 BRINKER DR
Practice Address - Street 2:RO #1
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144
Practice Address - Country:US
Practice Address - Phone:518-286-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098837-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00347888Medicaid
NYDM31567BMedicare ID - Type Unspecified
B78974Medicare UPIN