Provider Demographics
NPI:1548396047
Name:MOULTON, MARLENE S (MD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:S
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARLENE
Other - Middle Name:ST JOAN
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13421 PARKER COMMONS BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-2076
Mailing Address - Country:US
Mailing Address - Phone:239-985-2600
Mailing Address - Fax:239-985-0103
Practice Address - Street 1:14090 METROPOLIS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4450
Practice Address - Country:US
Practice Address - Phone:239-985-2600
Practice Address - Fax:239-985-0103
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94816207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281398000Medicaid
FL01028400Medicaid
FLI15048Medicare UPIN