Provider Demographics
NPI:1255419362
Name:MOODY, VIRGINIA J (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:J
Last Name:MOODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:405 KAYS DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-862-0064
Mailing Address - Fax:309-862-1542
Practice Address - Street 1:405 KAYS DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-862-0064
Practice Address - Fax:309-862-1542
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361015782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
260051695OtherRR MEDICARE
067425OtherHEALTH ALLIANCE
5723204OtherBCBS
437668OtherHEALTH LINK
067425OtherHEALTH ALLIANCE
260051695OtherRR MEDICARE