=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023212396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC MICHAEL MOZELESKI DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 08/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4881 SUGAR MAPLE DR
-----------------------------------------------------
City | WRIGHT PATTERSON AFB
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-257-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 BECKLEY FARM WAY
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066-9485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-926-8229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 34.012831
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------