Provider Demographics
NPI:1356310148
Name:MOODY, GARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1285 NININGER RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-1086
Mailing Address - Country:US
Mailing Address - Phone:651-480-4200
Mailing Address - Fax:651-480-4306
Practice Address - Street 1:1285 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1086
Practice Address - Country:US
Practice Address - Phone:651-480-4200
Practice Address - Fax:651-480-4306
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN22698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN30229200OtherMEDICAID WI
MN66-07826OtherMEDICA URGENT CARE
MNHP11055OtherHEALTH PARTNERS
MN01-11650OtherMEDICA
MN102582OtherUCARE MINNESOTA
MN760387800Medicaid
MN30229200OtherGROUP HEALTH EAU CLAIRE
MNNA9140186005OtherPREFERRED ONE
MN080194898OtherRAILROAD MEDICARAE
MN472S5M0OtherBLUE CROSS
MNNA9140186005OtherPREFERRED ONE
MN080012128Medicare ID - Type Unspecified