Provider Demographics
NPI:1487643946
Name:MOODY, CHESTER D III (MD)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:D
Last Name:MOODY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 VISTA WAY
Mailing Address - Street 2:SUITE 405
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3622
Mailing Address - Country:US
Mailing Address - Phone:760-439-6581
Mailing Address - Fax:760-439-6585
Practice Address - Street 1:25500 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5965
Practice Address - Country:US
Practice Address - Phone:909-696-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG084793174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G847930Medicaid
CA00G847930Medicare ID - Type Unspecified
CA00G847930Medicaid