Provider Demographics
NPI:1194789453
Name:MOFFETT, LARRY L (DO)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-659-0880
Mailing Address - Fax:503-513-7425
Practice Address - Street 1:11211 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7787
Practice Address - Country:US
Practice Address - Phone:503-659-0880
Practice Address - Fax:503-513-7425
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202942OtherWA LABOR & INDUSTRIES
OR159723Medicaid
OR159723Medicaid
OR106875Medicare ID - Type Unspecified