Provider Demographics
NPI:1285844183
Name:MOODY, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:1317 N ELM ST
Mailing Address - Street 2:STE. 1B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1033
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:501 N. ELAM AVENUE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL265352085R0001X
NC2008-006712085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909355Medicaid
VA1285844183Medicaid
NC2069888OtherWELLPATH/COVENTRY
NCP00838356OtherMEDICARE RAILROAD
NC2069888OtherWELLPATH/COVENTRY