Basic Information
| Provider Information | |||||||||
| NPI: | 1396773222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 825 SE BISHOP BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093322517 | ||||||||
| FaxNumber: | 5093349247 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 SE BISHOP BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093322517 | ||||||||
| FaxNumber: | 5093349247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | MD00025084 | WA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8131435 | 05 | WA | MEDICAID |