Provider Demographics
NPI:1962907071
Name:MOULTON, MICHAEL NICHOLAS (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NICHOLAS
Last Name:MOULTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BOATNER RD
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1391
Mailing Address - Country:US
Mailing Address - Phone:850-883-8600
Mailing Address - Fax:
Practice Address - Street 1:340 BOATNER RD
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2972207R00000X
MEDO2072207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine