Provider Demographics
NPI:1356319701
Name:MOODY, JOSHUA MARK (PT)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MARK
Last Name:MOODY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 WEST HAVENS
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301
Mailing Address - Country:US
Mailing Address - Phone:605-996-4778
Mailing Address - Fax:605-996-3660
Practice Address - Street 1:1319 WEST HAVENS
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301
Practice Address - Country:US
Practice Address - Phone:605-996-4778
Practice Address - Fax:605-996-3660
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5835000Medicaid
SDP00278968OtherMEDICARE RAILROAD
SDPT1145OtherDAKOTACARE
4994488OtherBCBS
SD45836OtherSANFORD
SDS100500Medicare PIN