Basic Information
| Provider Information | |||||||||
| NPI: | 1124000187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | WINFRED | ||||||||
| MiddleName: | DERRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2295 CAPE COURAGE WAY | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300242760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783718167 | ||||||||
| FaxNumber: | 6783768983 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 OLD NORCROSS RD | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300464308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709625040 | ||||||||
| FaxNumber: | 7709625056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 045299 | GA | N | Other Service Providers | Legal Medicine | 207N00000X | 045299 | GA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 000821158A | 05 | GA | MEDICAID |