Provider Demographics
NPI:1164404513
Name:MOODY, JON RICE (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:RICE
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LOWELL DR SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-535-5954
Practice Address - Street 1:420 LOWELL DR SE
Practice Address - Street 2:SUITE 106
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3754
Practice Address - Country:US
Practice Address - Phone:256-535-5964
Practice Address - Fax:256-535-5963
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51082080OtherBLUE CROSS BLUE SHIELD
0004123794OtherAETNA
631024475OtherTAX ID
AL000082080Medicaid
110031761OtherRAILROAD MEDICARE
631024475OtherTAX ID
000082080Medicare PIN
000082080Medicare ID - Type Unspecified