Provider Demographics
NPI:1447201801
Name:MOULTON, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
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 1:1105 CENTRAL EXPY N
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6103
Mailing Address - Country:US
Mailing Address - Phone:972-747-5437
Mailing Address - Fax:972-747-5497
Practice Address - Street 1:1105 CENTRAL EXPY N
Practice Address - Street 2:SUITE 250
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6103
Practice Address - Country:US
Practice Address - Phone:972-747-5437
Practice Address - Fax:972-747-5497
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1138208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202347093OtherIRS GROUP TAX ID
TXG66448Medicare UPIN