Basic Information
| Provider Information | |||||||||
| NPI: | 1902808793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1829 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838161829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086663200 | ||||||||
| FaxNumber: | 2086663397 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086663200 | ||||||||
| FaxNumber: | 2086663217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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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 | 2085R0202X | M8418 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8314395 | 05 | WA | MEDICAID | J6667 | 01 | ID | BC ID - CDA | OTHER | P00093894 | 01 | ID | RR MEDICARE - RANI | OTHER | 48918 | 01 | ID | BC ID - RANI | OTHER | 806398400 | 05 | ID | MEDICAID | 300136147 | 01 | ID | RR MEDICARE | OTHER | 1106376 | 01 | ID | CIGNA MEDICARE - RANI | OTHER | B1220 | 01 | ID | BC ID - PF | OTHER |