Provider Demographics
NPI:1902808793
Name:MOODY, DAVID ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ERNEST
Last Name:MOODY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6309
Practice Address - Fax:208-625-6310
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-84182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8314395Medicaid
IDJ6667OtherBC ID - CDA
IDP00093894OtherRR MEDICARE - RANI
ID48918OtherBC ID - RANI
ID806398400Medicaid
ID300136147OtherRR MEDICARE
ID1106376OtherCIGNA MEDICARE - RANI
IDB1220OtherBC ID - PF
ID300136147OtherRR MEDICARE
IDB1220OtherBC ID - PF