Provider Demographics
NPI:1417393893
Name:MOULTRIE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOULTRIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6115 PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:678-320-3630
Mailing Address - Fax:404-256-0121
Practice Address - Street 1:6115 PEACHTREE DUNWOODY ROAD
Practice Address - Street 2:SUITE 350
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:678-320-3630
Practice Address - Fax:404-256-0121
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine