Provider Demographics
NPI:1891820254
Name:MOODY, RUMANTHA (MD)
Entity Type:Individual
Prefix:MS
First Name:RUMANTHA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:RUMANATHA
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:65 HAWTHORNE PL
Mailing Address - Street 2:G-2
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2621
Mailing Address - Country:US
Mailing Address - Phone:973-509-5782
Mailing Address - Fax:
Practice Address - Street 1:1 LOWER MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879
Practice Address - Country:US
Practice Address - Phone:732-727-2555
Practice Address - Fax:732-727-0255
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32707207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1074504Medicaid
NJ1074504Medicaid
NJ052166DMPMedicare ID - Type Unspecified