MEDICARE: JAMES A. MOODY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	ME0052108	FL
2	208600000X	Surgery Physician	0101033738	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699775494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES A. MOODY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 368
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32540-0368
Country	:	US
Telephone Number	:	850-837-8831
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 MOUNTAIN DR
Second Line	:	SUITE # 6
City	:	DESTIN
State	:	FL
Zip	:	32541-7327
Country	:	US
Telephone Number	:	850-837-8831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	10/07/2010

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