Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 142675 | NY |
NPI | 1003804386 |
---|---|
Provider Name | Douglas Howard Moffat |
First Address | Hamburg, NY 14075-5304 |
Second Address | Buffalo, NY 14213-1205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00708338 | (05) | NY |
B36153 | (02) |