Healthcare Provider Details

I. General information

NPI: 1568411007
Provider Name (Legal Business Name): COLIN LEE MOFFETT D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 3RD AVE
GASTONIA NC
28052-4317
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-874-3300
  • Fax:
Mailing address:
  • Phone: 704-874-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number139
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number139
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: