Provider Demographics
NPI:1053435321
Name:MOESLEIN, FRED M (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:M
Last Name:MOESLEIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E CAMPUS VIEW BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-8628
Mailing Address - Country:US
Mailing Address - Phone:614-384-7177
Mailing Address - Fax:614-947-8309
Practice Address - Street 1:100 E CAMPUS VIEW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-8628
Practice Address - Country:US
Practice Address - Phone:614-384-7177
Practice Address - Fax:614-947-8309
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD4317322085R0204X
OH35.0876892085R0204X
PAMD431732174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD431732OtherPA MD LICENSE
FL017988100Medicaid