Provider Demographics
NPI:1891282489
Name:MOOTY, ALICIA MARIE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:MOOTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 JOHNSTON WILLIS DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-2369
Mailing Address - Country:US
Mailing Address - Phone:804-320-3668
Mailing Address - Fax:
Practice Address - Street 1:1465 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-2323
Practice Address - Country:US
Practice Address - Phone:804-320-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006944213ES0103X
390200000X
VA0103301334213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program