Provider Demographics
NPI:1609816172
Name:MOODY, CANDACE E (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:E
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 1:215 E MANSION ST
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1559
Mailing Address - Country:US
Mailing Address - Phone:269-781-4267
Mailing Address - Fax:269-781-2710
Practice Address - Street 1:4200 NORTHSIDE PKWY NW STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-3007
Practice Address - Country:US
Practice Address - Phone:404-448-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085398208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI481573Medicaid
MI872987Medicare UPIN
MI481573Medicaid