Provider Demographics
NPI:1669651980
Name:STEPHEN J MOFFETT OD A PROFESSIONAL
Entity type:Organization
Organization Name:STEPHEN J MOFFETT OD A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD A PROFESSIONAL
Authorized Official - Phone:619-435-6221
Mailing Address - Street 1:950 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2610
Mailing Address - Country:US
Mailing Address - Phone:619-435-6221
Mailing Address - Fax:619-435-6289
Practice Address - Street 1:950 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2610
Practice Address - Country:US
Practice Address - Phone:619-435-6221
Practice Address - Fax:619-435-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11550T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU84279Medicare UPIN
CAWOP11550AMedicare PIN
CAW16419Medicare PIN