1265417216 NPI number — DR. JEFFREY M MOLDOVAN DO

Table of content: DR. JEFFREY M MOLDOVAN DO (NPI 1265417216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265417216 NPI number — DR. JEFFREY M MOLDOVAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLDOVAN
Provider First Name:
JEFFREY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1265417216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 DARROW RD
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44236-5026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-656-5911
Provider Business Mailing Address Fax Number:
330-656-5901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
667 EASTLAND AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44484-4503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-841-4000
Provider Business Practice Location Address Fax Number:
330-841-4007
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  34005203 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000383091 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0856328 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000028430 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 001272239-0014 . This is a "PENNSYLVANIA MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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