Provider Demographics
NPI:1831861335
Name:MOODY, IRMA MAGDALENA
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:MAGDALENA
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2882 GREENTREE WAY
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-1225
Mailing Address - Country:US
Mailing Address - Phone:541-905-1624
Mailing Address - Fax:
Practice Address - Street 1:4010 AERIAL WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9757
Practice Address - Country:US
Practice Address - Phone:541-242-8300
Practice Address - Fax:541-242-8355
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR202113246NP-PP207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program