Provider Demographics
NPI:1346356102
Name:MOODY, PETER CAMPBELL (MD)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:CAMPBELL
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 1:1286 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3457
Mailing Address - Country:US
Mailing Address - Phone:810-733-3780
Mailing Address - Fax:810-230-1672
Practice Address - Street 1:1286 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3457
Practice Address - Country:US
Practice Address - Phone:810-733-3780
Practice Address - Fax:810-230-1672
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040461207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI02510801OtherBCBS
MI4697529Medicaid
MI02510801OtherBCBS
MI4697529Medicaid