Provider Demographics
NPI:1689695736
Name:MOULTON, ANTHONY LE ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:LE ROY
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 RANDALL SQ
Mailing Address - Street 2:STE 414
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-331-4175
Mailing Address - Fax:401-331-5718
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:STE 414
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-331-4175
Practice Address - Fax:401-331-5718
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI079657208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020315Medicaid
RI9020315Medicaid