Provider Demographics
NPI:1700580487
Name:MOODY, CHRISTOPHER GUNNAR (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:GUNNAR
Last Name:MOODY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 COBBLESTONE PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2050
Mailing Address - Country:US
Mailing Address - Phone:479-414-4405
Mailing Address - Fax:
Practice Address - Street 1:764 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4651
Practice Address - Country:US
Practice Address - Phone:601-984-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS390200000X
MST-5034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program