Provider Demographics
NPI:1386605368
Name:MOFFITT, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 S PAGOSA BLVD
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8329
Mailing Address - Country:US
Mailing Address - Phone:970-731-3700
Mailing Address - Fax:970-731-3707
Practice Address - Street 1:95 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8329
Practice Address - Country:US
Practice Address - Phone:970-731-3700
Practice Address - Fax:970-731-3707
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8664207R00000X, 207RH0002X
CODR.0049708207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH42058Medicare UPIN
TX8D0391Medicare ID - Type Unspecified
TX8P9114OtherBLUE SHIELD
TX1451957-05Medicaid
TXP00184728OtherRR/MEDICARE