Provider Demographics
NPI:1679541676
Name:MOUDY, CLIFFORD LOREN II (IDC)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:LOREN
Last Name:MOUDY
Suffix:II
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 104TH ST
Mailing Address - Street 2:
Mailing Address - City:TREVOR
Mailing Address - State:WI
Mailing Address - Zip Code:53179-9619
Mailing Address - Country:US
Mailing Address - Phone:847-688-2616
Mailing Address - Fax:
Practice Address - Street 1:3001A SIXTH ST
Practice Address - Street 2:NAVAL HOSPITAL GREAT LAKES
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-5230
Practice Address - Country:US
Practice Address - Phone:847-688-2616
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman