Provider Demographics
NPI:1346359197
Name:MOODY, DAVID LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
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:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-0435
Mailing Address - Country:US
Mailing Address - Phone:601-267-3625
Mailing Address - Fax:
Practice Address - Street 1:1071 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3601
Practice Address - Country:US
Practice Address - Phone:601-267-4562
Practice Address - Fax:601-267-4589
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017434Medicaid
B66160Medicare UPIN