Provider Demographics
NPI:1568568236
Name:MOODIE, DONNA (RD CDE)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:MOODIE
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 GREENHAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1607
Mailing Address - Country:US
Mailing Address - Phone:631-261-9739
Mailing Address - Fax:
Practice Address - Street 1:1556 STRAIGHT PATH
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3213
Practice Address - Country:US
Practice Address - Phone:631-854-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY896131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP92269Medicare UPIN
NY9131E1Medicare ID - Type Unspecified