MEDICARE: DR. DANA CHARLES MOFFATT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	11014752A	IN

General Provider Information

NPI Number	:	1033442991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANA CHARLES MOFFATT MD

Provider Business Mailing Address
First Line	:	359 N WEST ST
Second Line	:	APT 284
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-4207
Country	:	US
Telephone Number	:	131-769-8919
Fax Number	:

Provider Business Practice Location Address
First Line	:	359 N WEST ST
Second Line	:	APT 284
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-4207
Country	:	US
Telephone Number	:	131-769-8919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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