Provider Demographics
NPI:1285610766
Name:MOOTE, DOUGLAS J (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MOOTE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-291-6554
Mailing Address - Fax:860-783-5733
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-289-3375
Practice Address - Fax:860-560-2849
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2018-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA2462612085R0202X
CT0384782085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010038478CT01OtherANTHEM BC/BS
CT001384784Medicaid
CTA2516306OtherOXFORD
CTH14194Medicare UPIN
CT001384784Medicaid