Provider Demographics
NPI:1316987456
Name:MOULTON, JOHN PORTER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PORTER
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE
Mailing Address - Street 2:STE 6055
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2302
Mailing Address - Country:US
Mailing Address - Phone:509-455-9090
Mailing Address - Fax:509-747-2118
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:STE 6055
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-455-9090
Practice Address - Fax:509-747-2118
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000158372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1048644Medicaid
WAA07521Medicare UPIN
WA8801996Medicare PIN