Provider Demographics
NPI:1659682946
Name:MOODY, MAYA ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:ELIZABETH
Last Name:MOODY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S. NEW BALLAS ROAD
Mailing Address - Street 2:MERCY JFK CLINIC
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-6382
Mailing Address - Fax:
Practice Address - Street 1:615 S. NEW BALLAS ROAD
Practice Address - Street 2:MERCY JFK CLINIC
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-251-6382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013013923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics