Provider Demographics
NPI:1053832402
Name:MOODY, DEBORAH WOODS (LICENSED DISPENSING)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:WOODS
Last Name:MOODY
Suffix:
Gender:F
Credentials:LICENSED DISPENSING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4412
Mailing Address - Country:US
Mailing Address - Phone:404-618-0212
Mailing Address - Fax:
Practice Address - Street 1:6803 EDMONTON CT.
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058
Practice Address - Country:US
Practice Address - Phone:404-618-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001395156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician