MEDICARE: DR. MICHAEL DOMINIC MOZZETTI SR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME069032	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32306	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265591259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DOMINIC MOZZETTI SR. MD

Provider Business Mailing Address
First Line	:	3161 HARBOR BLVD
Second Line	:	SUITE A
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6754
Country	:	US
Telephone Number	:	941-629-1218
Fax Number	:	941-625-9465

Provider Business Practice Location Address
First Line	:	3161 HARBOR BLVD
Second Line	:	SUITE A
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6754
Country	:	US
Telephone Number	:	941-629-1218
Fax Number	:	941-625-9465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	03/22/2017

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