Provider Demographics
NPI:1962489179
Name:MOFFA, JOHN K (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:MOFFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:KEVIN
Other - Last Name:MOFFA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4030 WEST HENDERSON ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220
Mailing Address - Country:US
Mailing Address - Phone:614-442-7550
Mailing Address - Fax:614-442-4100
Practice Address - Street 1:4030 WEST HENDERSON ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220
Practice Address - Country:US
Practice Address - Phone:614-442-7550
Practice Address - Fax:614-442-4100
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-1014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2046075Medicaid
OHG56626Medicare UPIN
OH2046075Medicaid