Provider Demographics
NPI:1952466583
Name:MOODY, MICHAEL SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANNON
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8464 ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1839
Mailing Address - Country:US
Mailing Address - Phone:770-949-9804
Mailing Address - Fax:770-949-9842
Practice Address - Street 1:8464 ADAIR SREET
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1877
Practice Address - Country:US
Practice Address - Phone:770-949-9804
Practice Address - Fax:770-949-9842
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BDPJTMedicare ID - Type Unspecified
GAF73661Medicare UPIN