Provider Demographics
NPI:1962470740
Name:MOYA, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MOYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NORTHGATE LN
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-9558
Mailing Address - Country:US
Mailing Address - Phone:610-908-2995
Mailing Address - Fax:
Practice Address - Street 1:647 MALIN RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2621
Practice Address - Country:US
Practice Address - Phone:610-908-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048581L2085R0202X, 2085R0204X
WAMD000484712085R0204X
NJ25MA067850002085R0204X
TXP37782085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6895808Medicaid
NJP00391336OtherRR MEDICARE
NJ6895808Medicaid
NJ100504ZC3BMedicare PIN
PA776423Medicare PIN
WAG8881482Medicare PIN
G00390Medicare UPIN
PA776423Medicare ID - Type Unspecified
NJ100504ZC0QMedicare PIN