Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | M-6263 | ID |
NPI | 1003858465 |
---|---|
Provider Name | Dr. Darryl G Moffett JR. |
First Address | Ammon, ID 83406-6911 |
Second Address | Ammon, ID 83406-6911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2006 |
Last Update Date | 13/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002726100 | (05) | ID |
E91684 | (02) | ID |