Provider Demographics
NPI:1215013156
Name:MOULTON, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
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 1:2222 28TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2702
Mailing Address - Country:US
Mailing Address - Phone:718-721-2780
Mailing Address - Fax:
Practice Address - Street 1:2432 GRAND CONCOURSE
Practice Address - Street 2:POE CLINIC
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458
Practice Address - Country:US
Practice Address - Phone:718-579-7337
Practice Address - Fax:718-817-7904
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1685932080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01232099Medicaid
NY01232099Medicaid