Basic Information
| Provider Information | |||||||||
| NPI: | 1013206481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOSS AND MAIOCCO MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 2033714056 | ||||||||
| Practice Location | |||||||||
| Address1: | 4639 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033745546 | ||||||||
| FaxNumber: | 2033714056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 02/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | MAIOCCO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | KENNETH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2033745130 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 4191491 | 05 | CT | MEDICAID |