Provider Demographics
NPI:1174628275
Name:MOULTON, JOHN STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:MOULTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:721 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-3957
Mailing Address - Country:US
Mailing Address - Phone:817-426-4240
Mailing Address - Fax:817-426-3654
Practice Address - Street 1:6300 OAKMONT BLVD
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-2813
Practice Address - Country:US
Practice Address - Phone:817-294-2010
Practice Address - Fax:817-294-2024
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3280TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX917825Medicaid
TX917825Medicaid
TXT14955Medicare UPIN