Provider Demographics
NPI:1104895549
Name:MOODY, DAVID LEON JR (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEON
Last Name:MOODY
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9511 DELEGATES ROW
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3807
Mailing Address - Country:US
Mailing Address - Phone:317-571-1480
Mailing Address - Fax:
Practice Address - Street 1:9511 DELEGATES ROW
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3807
Practice Address - Country:US
Practice Address - Phone:317-571-1480
Practice Address - Fax:317-571-1481
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001932A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200296690AMedicaid
IN200296690AMedicaid
INU80605Medicare UPIN
INM400062510Medicare PIN