Provider Demographics
NPI:1710308762
Name:MOODY, SUSAN VIRGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:VIRGINIA
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:MOODY
Other - Last Name:NUNLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:210 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6052
Mailing Address - Country:US
Mailing Address - Phone:318-357-3122
Mailing Address - Fax:
Practice Address - Street 1:210 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6052
Practice Address - Country:US
Practice Address - Phone:318-357-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.0227212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry