1154326726 NPI number — DR. EVERETT ALBERT MOODY M.D.

Table of content: DR. EVERETT ALBERT MOODY M.D. (NPI 1154326726)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154326726 NPI number — DR. EVERETT ALBERT MOODY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOODY
Provider First Name:
EVERETT
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154326726
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/24/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 N MACARTHUR BLVD
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75062-4404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-258-7979
Provider Business Mailing Address Fax Number:
972-570-5502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 N MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75062-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-258-7979
Provider Business Practice Location Address Fax Number:
972-570-5502
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  D0977 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 74309 . This is a "AMERIGROUP ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8091K0 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 9001 . This is a "COMMISSION FOR THE BLIND" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4821 . This is a "PARKLAND MEDICAID ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 11369 . This is a "OPTICARE ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2224973 . This is a "BLUE LINK ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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