Provider Demographics
NPI:1700280351
Name:MOODY, MARK (AA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2125
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2125
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-395-4110
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:334-279-1450
Practice Address - Fax:334-395-4110
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7370367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant