1770586653 NPI number — DR. DAVID S MOORTHI M.D

Table of content: DR. DAVID S MOORTHI M.D (NPI 1770586653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770586653 NPI number — DR. DAVID S MOORTHI M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORTHI
Provider First Name:
DAVID
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1770586653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 IRVING AVE STE 418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13210-1573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-218-5303
Provider Business Mailing Address Fax Number:
315-471-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 IRVING AVE STE 418
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-1573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-218-5303
Provider Business Practice Location Address Fax Number:
315-471-0411
Provider Enumeration Date:
05/24/2005

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: 2081P2900X , with the licence number:  214078 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 214078 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00026146103 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200995527 . This is a "AMERICAN PROGRESSIVE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200995527 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 608856700 . This is a "DOL-OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 786892 . This is a "MVP" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010214078 . This is a "BLUECHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 200995527 . This is a "CHAMPUS VA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2140788B . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7001141 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8799848 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: RC60214078 . This is a "NOVA" identifier . This identifiers is of the category "OTHER".
  • Identifier: RC60214078 . This is a "POMCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110836AH . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200995527 . This is a "EMPIRE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P020214078 . This is a "EXCELLUS BCBS" identifier . This identifiers is of the category "OTHER".