Basic Information
| Provider Information | |||||||||
| NPI: | 1003804386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOFFAT | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 E PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140755304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166461233 | ||||||||
| FaxNumber: | 7168824426 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142131205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168824900 | ||||||||
| FaxNumber: | 4168824426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 142675 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00708338 | 05 | NY | MEDICAID |