Provider Demographics
NPI:1356645287
Name:MOODY, NATHAN RAYMOND (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RAYMOND
Last Name:MOODY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-4603
Mailing Address - Country:US
Mailing Address - Phone:205-965-3923
Mailing Address - Fax:
Practice Address - Street 1:930 NORTH CENTRAL EXPRESSWAY
Practice Address - Street 2:STE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-265-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.003731390200000X
TXR6845207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program