Provider Demographics
NPI:1891758926
Name:MOULTON, RICHARD E (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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 1:1400 MERCY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1836
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-830-2764
Practice Address - Street 1:1400 MERCY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1836
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-830-2764
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027415207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1789986Medicaid
MI4301027415OtherSTATE LICENSE
MI4301027415OtherSTATE LICENSE
MI0616311Medicare ID - Type Unspecified