Healthcare Provider Details

I. General information

NPI: 1598923021
Provider Name (Legal Business Name): LISA CAROLYN MOODY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 11/05/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 DULUTH PARK LN STE 290
DULUTH GA
30096-8511
US

IV. Provider business mailing address

7635 BLANDFORD PL
ATLANTA GA
30350-5603
US

V. Phone/Fax

Practice location:
  • Phone: 706-489-9623
  • Fax:
Mailing address:
  • Phone: 409-877-8875
  • Fax: 770-676-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA129944
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberP6470
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number79247
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number79247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: