1023291713 NPI number — DR. JAMES R MOULTON II M.D.

Table of content: DR. JAMES R MOULTON II M.D. (NPI 1023291713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023291713 NPI number — DR. JAMES R MOULTON II M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOULTON
Provider First Name:
JAMES
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
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:
MOULTON
Provider Other First Name:
JAMES
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
II
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023291713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2069 TERON TRACE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DACULA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30019-8716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-995-9100
Provider Business Mailing Address Fax Number:
770-822-9444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2069 TERON TRCE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DACULA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30019-1665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-995-9100
Provider Business Practice Location Address Fax Number:
770-822-9444
Provider Enumeration Date:
12/17/2007

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: 207V00000X , with the licence number:  043436 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 309499 . This is a "WELLCARE MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5554055 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4804710 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000750362B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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