Healthcare Provider Details

I. General information

NPI: 1609907294
Provider Name (Legal Business Name): LAURA MARIA MOODY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 HUBBARD DR
DEARBORN MI
48126-2641
US

IV. Provider business mailing address

19401 HUBBARD DR
DEARBORN MI
48126-2641
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8261
  • Fax:
Mailing address:
  • Phone: 313-982-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number4301052545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: