1003073214 NPI number — MICHAEL D MOZZETTI MD PL

Table of content: (NPI 1003073214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003073214 NPI number — MICHAEL D MOZZETTI MD PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL D MOZZETTI MD PL
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:
6
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:
1003073214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3161 HARBOR BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-6754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-629-1218
Provider Business Mailing Address Fax Number:
941-625-9465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3161 HARBOR BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-6754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-629-1218
Provider Business Practice Location Address Fax Number:
941-625-9465
Provider Enumeration Date:
05/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOZZETTI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
DOMINIC
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-629-1218

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME069032 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32306 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1867775 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 262587296 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 262587296 . This is a "BCBS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 262587296 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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