Provider Demographics
NPI:1487793246
Name:MOZDEN, WALTER S (LO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:S
Last Name:MOZDEN
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CLINIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2915
Mailing Address - Country:US
Mailing Address - Phone:860-889-9887
Mailing Address - Fax:860-889-0017
Practice Address - Street 1:7 CLINIC DRIVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2915
Practice Address - Country:US
Practice Address - Phone:860-889-9887
Practice Address - Fax:860-889-0017
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001299156FC0800X
CT000818156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT112397OtherEYEMED VISION CARE
CTZ56789OtherOPTI CARE
CT100000818CT02OtherANTHEM BLUE CROSS BLUE SH
CT4053690Medicaid
CT523231OtherCONNECITCARE
CT4053690Medicaid