Provider Demographics
NPI:1497794697
Name:MOODY, LOUISE GILMER (MD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:GILMER
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 EXFAIR RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2354
Mailing Address - Country:US
Mailing Address - Phone:301-869-0700
Mailing Address - Fax:301-948-1751
Practice Address - Street 1:803 RUSSELL AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3584
Practice Address - Country:US
Practice Address - Phone:301-869-0700
Practice Address - Fax:301-948-1751
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD30047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000H55S79Medicare ID - Type Unspecified
MDC88940Medicare UPIN