Provider Demographics
NPI:1265591259
Name:MOZZETTI, MICHAEL DOMINIC SR (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOMINIC
Last Name:MOZZETTI
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3161 HARBOR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6754
Mailing Address - Country:US
Mailing Address - Phone:941-629-1218
Mailing Address - Fax:941-625-9465
Practice Address - Street 1:3161 HARBOR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6754
Practice Address - Country:US
Practice Address - Phone:941-629-1218
Practice Address - Fax:941-625-9465
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME069032207Q00000X
FLME 69032207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32306OtherBLUE CROSS BLUE SHIELD
FL32306Medicare ID - Type Unspecified
A52022Medicare UPIN