1639218126 NPI number — MRS. ESTHER BARBARA MOERTH DOM,LAC,DIPL.CH

Table of content: NATHAN D JOHNSON O.D. (NPI 1427130368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639218126 NPI number — MRS. ESTHER BARBARA MOERTH DOM,LAC,DIPL.CH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOERTH
Provider First Name:
ESTHER
Provider Middle Name:
BARBARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DOM,LAC,DIPL.CH
Provider Gender Code:
F

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:
1639218126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 901
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENDELL
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01379-0901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-313-7290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
974 WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRATTLEBORO
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05301-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-313-7290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2007

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: 171100000X , with the licence number:  731 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201044209 . This is a "PRESBYTHERIAN PROVIDER ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 900179757 . This is a "TAX ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM024G04 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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