Provider Demographics
NPI:1376704577
Name:MOULDER, PETER VINCENT IV (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:VINCENT
Last Name:MOULDER
Suffix:IV
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 1:157 WATERDAM RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-2573
Mailing Address - Country:US
Mailing Address - Phone:724-941-7144
Mailing Address - Fax:724-941-7625
Practice Address - Street 1:157 WATERDAM RD STE 120
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2573
Practice Address - Country:US
Practice Address - Phone:724-941-7144
Practice Address - Fax:724-941-7625
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD442651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102617399Medicaid