Provider Demographics
NPI:1043217102
Name:MOODY, IRENE JUNE (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:JUNE
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1148
Mailing Address - Country:US
Mailing Address - Phone:505-265-7817
Mailing Address - Fax:505-266-1543
Practice Address - Street 1:3410 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1148
Practice Address - Country:US
Practice Address - Phone:505-265-7817
Practice Address - Fax:505-266-1543
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30742Medicaid
NM30742Medicaid