Provider Demographics
NPI:1821787367
Name:MOODY, DOMONIQUE (MLS, PBT)
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:MLS, PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 E 151ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5172
Mailing Address - Country:US
Mailing Address - Phone:347-867-1188
Mailing Address - Fax:
Practice Address - Street 1:757 ALPHA DR STE C
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-2173
Practice Address - Country:US
Practice Address - Phone:347-867-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253352207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine