Provider Demographics
NPI:1245275536
Name:MOODY, KASIMU SENGHOR (MD)
Entity type:Individual
Prefix:DR
First Name:KASIMU
Middle Name:SENGHOR
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:111 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-7689
Mailing Address - Country:US
Mailing Address - Phone:337-273-2588
Mailing Address - Fax:
Practice Address - Street 1:73153 MILITARY RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435-6054
Practice Address - Country:US
Practice Address - Phone:985-626-6133
Practice Address - Fax:985-626-6136
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14802R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH78525Medicare UPIN
LA4E893Medicare ID - Type Unspecified