Healthcare Provider Details

I. General information

NPI: 1124000187
Provider Name (Legal Business Name): WINFRED DERRICK MOODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 OLD NORCROSS RD SUITE #200
LAWRENCEVILLE GA
30046-4308
US

IV. Provider business mailing address

2295 CAPE COURAGE WAY
SUWANEE GA
30024-2760
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-5040
  • Fax: 770-962-5056
Mailing address:
  • Phone: 678-371-8167
  • Fax: 678-376-8983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number045299
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number045299
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: