Provider Demographics
NPI:1114000148
Name:MOULICK, ACHINTYA (MD)
Entity Type:Individual
Prefix:
First Name:ACHINTYA
Middle Name:
Last Name:MOULICK
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 1:3601 A STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-1095
Mailing Address - Country:US
Mailing Address - Phone:215-427-5109
Mailing Address - Fax:215-427-3860
Practice Address - Street 1:3601 A STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1095
Practice Address - Country:US
Practice Address - Phone:215-427-5109
Practice Address - Fax:215-427-3860
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035499208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
H31150Medicare UPIN