Basic Information
| Provider Information | |||||||||
| NPI: | 1477757839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | MECHELLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOODY | ||||||||
| OtherFirstName: | MECHELLE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4970 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324466802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507185620 | ||||||||
| FaxNumber: | 8507185670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4970 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324466802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507185620 | ||||||||
| FaxNumber: | 8507185670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 046890 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 046890 | 01 | GA | GA STATE LICENSE | OTHER |