Provider Demographics
NPI:1700288446
Name:MOODY, ZACHARY
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ZACHARY
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:3631 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2237
Mailing Address - Country:US
Mailing Address - Phone:405-306-9742
Mailing Address - Fax:
Practice Address - Street 1:3631 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2237
Practice Address - Country:US
Practice Address - Phone:773-725-2953
Practice Address - Fax:773-725-2932
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005627213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist