Healthcare Provider Details

I. General information

NPI: 1194948117
Provider Name (Legal Business Name): JOHN LINDSAY MOODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24961 THOMPSON DR
SEDRO WOOLLEY WA
98284-8246
US

IV. Provider business mailing address

4315 SHELBY CT
ANACORTES WA
98221-8773
US

V. Phone/Fax

Practice location:
  • Phone: 360-856-3115
  • Fax:
Mailing address:
  • Phone: 360-299-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD00016542
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: