Provider Demographics
NPI:1659554764
Name:MOODY, MILO LYMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MILO
Middle Name:LYMAN
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N 500 W
Mailing Address - Street 2:#104
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1541
Mailing Address - Country:US
Mailing Address - Phone:801-374-9299
Mailing Address - Fax:801-377-4220
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:#104
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-374-9299
Practice Address - Fax:801-377-4220
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT148865-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist