Provider Demographics
NPI:1609827377
Name:YASMEEN A MOODY MD PC
Entity Type:Organization
Organization Name:YASMEEN A MOODY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YASMEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-535-4644
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:202 TAUGHANNOCK BLVD
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851-0366
Mailing Address - Country:US
Mailing Address - Phone:607-277-3257
Mailing Address - Fax:607-277-4056
Practice Address - Street 1:1 FIRST STREET
Practice Address - Street 2:
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891
Practice Address - Country:US
Practice Address - Phone:607-535-4644
Practice Address - Fax:607-535-4744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01487916Medicaid
NYB82290Medicare UPIN
NY01487916Medicaid