Provider Demographics
NPI:1659440170
Name:MOODHE, CAROLE LYSAGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:LYSAGHT
Last Name:MOODHE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 PRO HEALTH PLZ
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1111
Mailing Address - Country:US
Mailing Address - Phone:516-506-6885
Mailing Address - Fax:516-608-6824
Practice Address - Street 1:2 PRO HEALTH PLZ
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1111
Practice Address - Country:US
Practice Address - Phone:516-506-6885
Practice Address - Fax:516-608-6824
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181854207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01437714Medicaid
NY06399OtherGHI MEDICARE
NY260AD1OtherEMPIRE BCBS MEDICARE
NY62K521OtherEMPIRE MEDICARE
NY00738981Medicaid
NYAP603OtherOXFORD MEDICARE
NY06399OtherGHI MEDICARE