Provider Demographics
NPI:1275566549
Name:MOODLEY, BRENDON ANDRONICUS (DPM)
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:ANDRONICUS
Last Name:MOODLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19633 93RD PL NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2380
Mailing Address - Country:US
Mailing Address - Phone:305-323-2882
Mailing Address - Fax:
Practice Address - Street 1:8980 161ST AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052
Practice Address - Country:US
Practice Address - Phone:425-899-1115
Practice Address - Fax:425-899-1116
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3187213ES0103X
WAPO 60112477213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery