Provider Demographics
NPI:1366418956
Name:MOODY ANTONIO, STEPHANIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:MOODY ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-388-6200
Mailing Address - Fax:757-388-6201
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6200
Practice Address - Fax:757-388-6201
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237385207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA174750OtherANTHEM
VAPAROtherUSA MANAGED CARE
VAPAROtherMULTIPLAN
VAPAROtherFIRST HEALTH COMMERCIAL
NC067RGOtherBC/BS
VA172403OtherANTHEM
VA91377OtherSENTARA OPTIMA
VAPAROtherVA PREMIER HEALTH
VAPAROtherCIGNA
VA-004OtherTRICARE/CHAMPUS
VA010170095Medicaid
VAPAROtherVA HEALTH NETWORK
VAPAROtherCORVEL/CORCARE
VA010118387Medicaid
VA2129791OtherUHC/MAMSI
VAPAROtherAETNA
NC89067RGMedicaid
VAPAROtherMULTIPLAN
VA172403OtherANTHEM
VAPAROtherCIGNA