Provider Demographics
NPI:1366447591
Name:MOODY, WAYNE A (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1638
Mailing Address - Country:US
Mailing Address - Phone:207-777-7111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:2 GREAT FALLS PLZ
Practice Address - Street 2:SUITE 21
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5966
Practice Address - Country:US
Practice Address - Phone:207-333-4710
Practice Address - Fax:207-333-4715
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-07-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME011739207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DX4496OtherNEW MEDICARE PTAN
010416156OtherTRAVELERS/CORE/MEDNET
0378600001OtherDMERC
200009601OtherRR MEDICARE
D03588OtherHARVARD
M4231OtherCIGNA
MM0716OtherMEDICARE CLINIC FACILITY
ME270310099OtherMAINECARE
001862OtherANTHEM
015612OtherMEDICARE
1044480OtherAETNA
100294000OtherUSPS WC
201017OtherMEDICARE ASC FACILITY
1044480OtherAETNA