1013195577 NPI number — WALTER S MOZDEN LO

Table of content: (NPI 1013195577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013195577 NPI number — WALTER S MOZDEN LO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTER S MOZDEN LO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013195577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 CLINIC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06360-2915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-889-9887
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 CLINIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06360-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-889-9887
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOZDEN
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-889-9887

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  001299 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100000818CT02 . This is a "LUMENOS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 19796 . This is a "SPECTERA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0187430001 . This is a "MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 100000818CT02 . This is a "BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".