1548396047 NPI number — MARLENE S MOULTON M.D.

Table of content: MARLENE S MOULTON M.D. (NPI 1548396047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548396047 NPI number — MARLENE S MOULTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOULTON
Provider First Name:
MARLENE
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOULTON
Provider Other First Name:
MARLENE
Provider Other Middle Name:
ST. JOAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548396047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13421 PARKER COMMONS BLVD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912-2076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-985-2600
Provider Business Mailing Address Fax Number:
239-985-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14090 METROPOLIS AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-985-2600
Provider Business Practice Location Address Fax Number:
239-985-0103
Provider Enumeration Date:
02/26/2007

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: 207R00000X , with the licence number:  ME94816 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 281398000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01028400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281398000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com