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General NPI Number Information
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NPI Number | 1093158578
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Entity Type | Individual
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Provider Name | MOODY MANKERIOUS DPM
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Gender | Male
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Dates
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Enumeration Date | 04/15/2013
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 8036 CAMP BOWIE WEST BLVD
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City | FORT WORTH
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State | TX
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Zip | 76116-6313
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Country | US
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Telephone | 817-494-0566
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Fax | 817-612-3157
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Provider Business Mailing Address
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Address Line | 8036 CAMP BOWIE WEST BLVD
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City | FORT WORTH
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State | TX
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Zip | 76116-6313
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Country | US
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Telephone | 817-494-0566
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Fax | 817-612-3157
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 2204
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License Number State | TX
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