Provider Demographics
NPI:1356332449
Name:MOULTON, STACY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:JAMES
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 1:10401 SPOTSYLVANIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8606
Mailing Address - Country:US
Mailing Address - Phone:540-361-1000
Mailing Address - Fax:540-361-7010
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-361-1000
Practice Address - Fax:540-361-7010
Is Sole Proprietor?:No
Enumeration Date:2005-10-29
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012397462085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00318336Medicare PIN
VA010558R20Medicare PIN
VA010556M99Medicare PIN
P00332456Medicare PIN
VA010558R20Medicare PIN
VAVAA102383Medicare PIN
VA010556M99Medicare PIN
P00318336Medicare PIN
FLH58990Medicare UPIN
P00332456Medicare PIN
VA010557M98Medicare PIN