Healthcare Provider Details

I. General information

NPI: 1962815415
Provider Name (Legal Business Name): MR. LARRY JAMES MOODY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PARKMOOR AVE
SAN JOSE CA
95126-3797
US

IV. Provider business mailing address

1400 PARKMOOR AVE
SAN JOSE CA
95126-3797
US

V. Phone/Fax

Practice location:
  • Phone: 408-510-3480
  • Fax: 408-510-3484
Mailing address:
  • Phone: 408-510-3480
  • Fax: 408-510-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: