Healthcare Provider Details

I. General information

NPI: 1740587708
Provider Name (Legal Business Name): ELLEN GRACE MOFFATT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2011
Last Update Date: 02/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 BRYANT ST HALL OF JUSTICE
SAN FRANCISCO CA
94103-4603
US

IV. Provider business mailing address

850 BRYANT ST HALL OF JUSTICE
SAN FRANCISCO CA
94103-4603
US

V. Phone/Fax

Practice location:
  • Phone: 415-553-1796
  • Fax: 415-553-1640
Mailing address:
  • Phone: 415-553-1796
  • Fax: 415-553-1640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberA66146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: