Healthcare Provider Details

I. General information

NPI: 1508166596
Provider Name (Legal Business Name): DIANA B MOISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-7446
  • Fax: 860-714-1508
Mailing address:
  • Phone: 860-714-7446
  • Fax: 860-714-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberBP20050261
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number053730
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: