Provider Demographics
NPI:1699775494
Name:MOODY, JAMES A (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:MOODY
Suffix:
Gender:M
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 368
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32540-0368
Mailing Address - Country:US
Mailing Address - Phone:850-837-8831
Mailing Address - Fax:
Practice Address - Street 1:415 MOUNTAIN DR
Practice Address - Street 2:SUITE # 6
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-7327
Practice Address - Country:US
Practice Address - Phone:850-837-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052108208600000X
VA0101033738208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048081900Medicaid
FLE69410Medicare UPIN
FL048081900Medicaid