Provider Demographics
NPI:1831141167
Name:MOFFA, NICHOLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:MOFFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:26 CITY HALL MALL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-306-5463
Mailing Address - Fax:781-306-5379
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5463
Practice Address - Fax:781-306-5379
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2355902084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000751901Medicare PIN