MEDICARE: LARRY L MOFFETT DO

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	207Q00000X	Family Medicine Physician	DO15179	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202942	OTHER	WA	WA LABOR & INDUSTRIES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194789453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY L MOFFETT DO

Provider Business Mailing Address
First Line	:	PO BOX 92900
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97292-0900
Country	:	US
Telephone Number	:	503-659-0880
Fax Number	:	503-513-7425

Provider Business Practice Location Address
First Line	:	11211 SE SUNNYSIDE RD
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-7787
Country	:	US
Telephone Number	:	503-659-0880
Fax Number	:	503-513-7425

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

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	03/17/2010

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