MEDICARE: DR. MOODY MANKERIOUS DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	2204	TX

General Provider Information

NPI Number	:	1093158578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOODY MANKERIOUS DPM

Provider Business Mailing Address
First Line	:	8036 CAMP BOWIE WEST BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6313
Country	:	US
Telephone Number	:	817-494-0566
Fax Number	:	817-612-3157

Provider Business Practice Location Address
First Line	:	8036 CAMP BOWIE WEST BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6313
Country	:	US
Telephone Number	:	817-494-0566
Fax Number	:	817-612-3157

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2013
Last Update Date	:	06/13/2025

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