Provider Demographics
NPI:1710999024
Name:MOULTON, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:988102 NEBRASKA MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-9800
Mailing Address - Fax:402-559-7929
Practice Address - Street 1:988102 NEBRASKA MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-9800
Practice Address - Fax:402-559-7929
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34904208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124508Medicaid
NE10026059800Medicaid
AZP00439640OtherRAILROAD MEDICARE
AZZ110994Medicare PIN
NE098605435Medicare PIN