1083677793 NPI number — SUZELLE L MOFFITT MD

Table of content: SUZELLE L MOFFITT MD (NPI 1083677793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083677793 NPI number — SUZELLE L MOFFITT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOFFITT
Provider First Name:
SUZELLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083677793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 HILL COUNTRY DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-6024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-258-7090
Provider Business Mailing Address Fax Number:
830-258-7098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 EL PASO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUIDOSO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88345-6033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-630-8350
Provider Business Practice Location Address Fax Number:
575-257-4055
Provider Enumeration Date:
04/11/2006

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: 207Q00000X , with the licence number:  H5566 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD2017-0489 , 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: 21107831 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8GA072 . This is a "BCBS PROVIDER ID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com