Provider Demographics
NPI:1538294897
Name:MOULTON, DONALD E (RN OTC)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:MOULTON
Suffix:
Gender:M
Credentials:RN OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4541
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4541
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083026191RN163W00000X
OR930064163WX0800X
OR930064 OT-SC374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No163W00000XNursing Service ProvidersRegistered Nurse
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherGROUP NPI NUMBER
OR930635514OtherGROUP TAX ID FOR BILLING
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER