Provider Demographics
NPI:1124000187
Name:MOODY, WINFRED DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:WINFRED
Middle Name:DERRICK
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 CAPE COURAGE WAY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2760
Mailing Address - Country:US
Mailing Address - Phone:678-371-8167
Mailing Address - Fax:678-376-8983
Practice Address - Street 1:565 OLD NORCROSS RD
Practice Address - Street 2:SUITE #200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4308
Practice Address - Country:US
Practice Address - Phone:770-962-5040
Practice Address - Fax:770-962-5056
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045299173000000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000821158AMedicaid
GA202I072926Medicare PIN
GA000821158AMedicaid
SCAA81879282Medicare PIN
GA07BBSFWMedicare ID - Type Unspecified