Provider Demographics
NPI:1760744403
Name:MOULTON, TRAVIS REED (DO)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:REED
Last Name:MOULTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277976
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE
Practice Address - Street 2:STE 230
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5407
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:208-442-6520
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine