Provider Demographics
NPI:1972688695
Name:MOFFAT, KELLY ANNE (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MOFFAT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5240 E KNIGHT DR
Mailing Address - Street 2:STE 104
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2122
Mailing Address - Country:US
Mailing Address - Phone:520-795-4202
Mailing Address - Fax:520-326-5317
Practice Address - Street 1:5240 E KNIGHT DR
Practice Address - Street 2:STE 104
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2122
Practice Address - Country:US
Practice Address - Phone:520-795-4202
Practice Address - Fax:520-326-5317
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ1183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ775249Medicaid
AZ775249Medicaid
AZZ74566Medicare PIN