Provider Demographics
NPI:1962415364
Name:DAN MOEZZI MD PC
Entity type:Organization
Organization Name:DAN MOEZZI MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOEZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-443-0339
Mailing Address - Street 1:2474 INDIAN WELLS RD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-3831
Mailing Address - Country:US
Mailing Address - Phone:575-443-0339
Mailing Address - Fax:575-434-5624
Practice Address - Street 1:2474 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-3831
Practice Address - Country:US
Practice Address - Phone:575-443-0339
Practice Address - Fax:575-434-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-302261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH1455Medicaid
NM201017118OtherPRESBYTERIAN HEALTH CARE
NMNM004493OtherBLUE CROSS BLUE SHIELD
NM201017118OtherPRESBYTERIAN HEALTH CARE
NMNM004493OtherBLUE CROSS BLUE SHIELD