Provider Demographics
NPI:1346413424
Name:MOODIE, KURTIS ROSENDO (MD)
Entity Type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:ROSENDO
Last Name:MOODIE
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 1:3498 CHATSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 29TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5125
Practice Address - Country:US
Practice Address - Phone:916-733-3777
Practice Address - Fax:916-454-6780
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084305207R00000X, 208000000X
CAA109098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics