Healthcare Provider Details

I. General information

NPI: 1649386038
Provider Name (Legal Business Name): RICHARD T. MOXLEY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 673
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5006
  • Fax: 585-273-1255
Mailing address:
  • Phone: 585-275-5006
  • Fax: 585-273-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number120854
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: