Individual
DR. WILLIS E MOODY III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
191 DEEP SOUTH FARM RD, BLAIRSVILLE, GA 30512-2220
(706) 781-6950
Mailing address
35 HOSPITAL RD, BLAIRSVILLE, GA 30512-3139
(706) 745-2111
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
058708
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000570534D
MEDICAID
GA
01
—
1487774261
GROUP NPI
GA
01
—
20-5788381
TAX ID
GA
01
—
386024
WELLCARE
GA
05
—
839014891
—
GA
01
—
GRP8005
GROUP IDENTIFIER
GA
Enumeration date
11/07/2005
Last updated
05/19/2023
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