Provider Demographics
NPI:1669695300
Name:MOFFITT, GARY L (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:MOFFITT
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 1:4001 WAGON WHEEL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0137
Mailing Address - Country:US
Mailing Address - Phone:479-725-3001
Mailing Address - Fax:479-725-3098
Practice Address - Street 1:4001 WAGON WHEEL RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0137
Practice Address - Country:US
Practice Address - Phone:479-725-3001
Practice Address - Fax:479-725-3098
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5918174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD04790Medicare UPIN