Provider Demographics
NPI:1003815598
Name:MOULTRIE, H CARL II (MD)
Entity Type:Individual
Prefix:
First Name:H
Middle Name:CARL
Last Name:MOULTRIE
Suffix:II
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:PO BOX 10727
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46411-0727
Mailing Address - Country:US
Mailing Address - Phone:219-793-9029
Mailing Address - Fax:219-793-9101
Practice Address - Street 1:255 E 90TH DR
Practice Address - Street 2:SUITE W1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-793-9029
Practice Address - Fax:219-793-9101
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026965A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4513204OtherAETNA
IN000000186722OtherANTHEM
IN131990IMedicare ID - Type Unspecified
D69716Medicare UPIN