Healthcare Provider Details

I. General information

NPI: 1851146435
Provider Name (Legal Business Name): MR. SAMUEL ALEXANDER MOFFET
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 RESERVOIR RD NW
WASHINGTON DC
20007-2126
US

IV. Provider business mailing address

3900 RESERVOIR RD NW
WASHINGTON DC
20007-2126
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-4922
  • Fax: 202-444-6292
Mailing address:
  • Phone: 202-444-4922
  • Fax: 202-444-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: