Provider Demographics
NPI:1477757839
Name:MOODY, MECHELLE L (MD)
Entity Type:Individual
Prefix:
First Name:MECHELLE
Middle Name:L
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MECHELLE
Other - Middle Name:L
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4970 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-6802
Mailing Address - Country:US
Mailing Address - Phone:850-718-5620
Mailing Address - Fax:850-718-5670
Practice Address - Street 1:4970 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-6802
Practice Address - Country:US
Practice Address - Phone:850-718-5620
Practice Address - Fax:850-718-5670
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA046890OtherGA STATE LICENSE
GA046890OtherGA STATE LICENSE