Provider Demographics
NPI:1366475592
Name:MOULTON, MARTHA (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 OLD NEW MILFORD RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2430
Mailing Address - Country:US
Mailing Address - Phone:203-775-6365
Mailing Address - Fax:
Practice Address - Street 1:60 OLD NEW MILFORD RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2430
Practice Address - Country:US
Practice Address - Phone:203-775-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1217832OtherUNITED HEALTHCARE
CT1316860Medicaid
CTZP704OtherOXFORD HEALTH PLANS
CT010031686CT01OtherANTHEM BCBS
CT061137531001OtherTRICARE
CT17542OtherCIGNA HEALTHCARE
CT801783OtherAETNA US HEALTHCARE
CT040369OtherHEALTH NET
CTZP704OtherOXFORD HEALTH PLANS