Basic Information
| Provider Information | |||||||||
| NPI: | 1396967980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOODLEY | ||||||||
| FirstName: | ENASH | ||||||||
| MiddleName: | SILVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11920 ASTORIA BLVD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770896097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814849369 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 36748 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 36748 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 36748 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RC0200X | Q6771 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 367481 | 05 | SC | MEDICAID |