Healthcare Provider Details

I. General information

NPI: 1225290737
Provider Name (Legal Business Name): LARA WEAR MOODY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 REMOUNT RD
NORTH CHARLESTON SC
29406-3433
US

IV. Provider business mailing address

1213 REMOUNT RD
NORTH CHARLESTON SC
29406-3433
US

V. Phone/Fax

Practice location:
  • Phone: 843-973-5415
  • Fax: 833-994-1101
Mailing address:
  • Phone: 843-973-5415
  • Fax: 833-994-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84179
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: