Healthcare Provider Details

I. General information

NPI: 1679509509
Provider Name (Legal Business Name): FREDERICK ALLEN MOFFA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 SALMON BROOK ST
GRANBY CT
06035-1804
US

IV. Provider business mailing address

20 COPPER HILL RD
GRANBY CT
06035-1524
US

V. Phone/Fax

Practice location:
  • Phone: 860-653-7440
  • Fax:
Mailing address:
  • Phone: 860-653-7440
  • Fax: 860-653-7469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2388
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: