Provider Demographics
NPI:1952588592
Name:MOODY, MARK JAMES (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5900 COYLE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0400
Mailing Address - Country:US
Mailing Address - Phone:916-344-9400
Mailing Address - Fax:916-344-9401
Practice Address - Street 1:5900 COYLE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0400
Practice Address - Country:US
Practice Address - Phone:916-344-9400
Practice Address - Fax:916-344-9401
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2011-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG38627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962422618OtherNPI
CAG38627OtherMEDICAL LICENSE
CA00G386270Medicaid
CA00G415210Medicare PIN