Provider Demographics
NPI:1457661605
Name:DESTIN SURGERY CLINIC, P.A.
Entity Type:Organization
Organization Name:DESTIN SURGERY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-837-8831
Mailing Address - Street 1:P.O. BOX 368
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32540
Mailing Address - Country:US
Mailing Address - Phone:850-837-8831
Mailing Address - Fax:850-837-9137
Practice Address - Street 1:415 MOUNTAIN DRIVE
Practice Address - Street 2:SUITE # 6
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-837-8831
Practice Address - Fax:850-837-9137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty