Basic Information
| Provider Information | |||||||||
| NPI: | 1083648299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOFFAT | ||||||||
| FirstName: | GERTRUDE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | CO MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 EDGELL RD | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086206615 | ||||||||
| FaxNumber: | 5088791597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 55828 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3091333 | 05 | MA | MEDICAID | 200181 | 01 | MA | HPHC | OTHER | J05630 | 01 | MA | BS | OTHER | 055828 | 01 | MA | TUFTS | OTHER |