Healthcare Provider Details

I. General information

NPI: 1255755328
Provider Name (Legal Business Name): MARIO MOYA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 MALIN RD
NEWTOWN SQUARE PA
19073-2621
US

IV. Provider business mailing address

647 MALIN RD
NEWTOWN SQUARE PA
19073-2621
US

V. Phone/Fax

Practice location:
  • Phone: 610-908-2995
  • Fax: 215-240-1677
Mailing address:
  • Phone: 610-908-2995
  • Fax: 215-240-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIO MOYA
Title or Position: CEO
Credential: MD
Phone: 610-908-2995