Healthcare Provider Details

I. General information

NPI: 1144665969
Provider Name (Legal Business Name): BRIAN THOMAS MOY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 TAMARACK AVE STE 101
SOUTH WINDSOR CT
06074
US

IV. Provider business mailing address

2400 TAMARACK AVE STE 101
SOUTH WINDSOR CT
06074-5556
US

V. Phone/Fax

Practice location:
  • Phone: 860-644-4442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number62317
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: