Healthcare Provider Details

I. General information

NPI: 1366447591
Provider Name (Legal Business Name): WAYNE A. MOODY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GREAT FALLS PLZ SUITE 21
AUBURN ME
04210-5966
US

IV. Provider business mailing address

PO BOX 1638
ALBANY NY
12201-1638
US

V. Phone/Fax

Practice location:
  • Phone: 207-333-4710
  • Fax: 207-333-4715
Mailing address:
  • Phone: 207-777-7111
  • Fax: 207-783-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number011739
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: