Provider Demographics
NPI:1841752458
Name:MOODY, DEREK LEE
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:LEE
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 NURSERY DR STE 202
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1688
Mailing Address - Country:US
Mailing Address - Phone:361-576-0633
Mailing Address - Fax:361-576-0639
Practice Address - Street 1:6404 NURSERY DR STE 202
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1688
Practice Address - Country:US
Practice Address - Phone:361-576-0633
Practice Address - Fax:361-576-0639
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU9610207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine