Provider Demographics
NPI:1144373010
Name:MOFFETT, MARTIN R (DC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:R
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2537
Mailing Address - Country:US
Mailing Address - Phone:618-937-3509
Mailing Address - Fax:618-937-3500
Practice Address - Street 1:607 W OAK ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2537
Practice Address - Country:US
Practice Address - Phone:618-937-3509
Practice Address - Fax:618-937-3500
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
929137OtherHEALTHLINK PIN
2832034OtherBLUE CROSS BLUE SHIELD OF ILLINOIS PIN
2832034OtherBLUE CROSS BLUE SHIELD OF ILLINOIS PIN