Provider Demographics
NPI: | 1700286564 |
---|---|
Name: | MORIAH R. MOFFITT, M.D., P.A. |
Entity Type: | Organization |
Organization Name: | MORIAH R. MOFFITT, M.D., P.A. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BUSINESS OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MORIAH |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | MOFFITT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 813-414-0908 |
Mailing Address - Street 1: | 603 S BOULEVARD |
Mailing Address - Street 2: | |
Mailing Address - City: | TAMPA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33606-2629 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 813-414-0908 |
Mailing Address - Fax: | 813-464-2853 |
Practice Address - Street 1: | 603 S BOULEVARD |
Practice Address - Street 2: | |
Practice Address - City: | TAMPA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33606-2629 |
Practice Address - Country: | US |
Practice Address - Phone: | 813-414-0908 |
Practice Address - Fax: | 813-464-2853 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-08-29 |
Last Update Date: | 2014-08-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME69284 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |