Healthcare Provider Details

I. General information

NPI: 1104041342
Provider Name (Legal Business Name): ROGER D MOCCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S ORANGE AVE FL 3
ORLANDO FL
32806-1215
US

IV. Provider business mailing address

1222 S ORANGE AVE FL 3
ORLANDO FL
32806-1215
US

V. Phone/Fax

Practice location:
  • Phone: 407-539-2100
  • Fax: 321-842-1569
Mailing address:
  • Phone: 407-539-2100
  • Fax: 321-842-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME120656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: