Provider Demographics
NPI:1033378989
Name:MOODY, GINA NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:MOODY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 W STATE ST
Mailing Address - Street 2:510
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1515
Mailing Address - Country:US
Mailing Address - Phone:614-464-0788
Mailing Address - Fax:614-464-0295
Practice Address - Street 1:745 W STATE ST
Practice Address - Street 2:510
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1515
Practice Address - Country:US
Practice Address - Phone:614-464-0788
Practice Address - Fax:614-464-0295
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-009373207R00000X
OH34.009373208M00000X
OH34009373207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2932974Medicaid
WV3810019460Medicaid
OH000000706454OtherANTHEM
OH4258623Medicare PIN