Provider Demographics
NPI:1770648032
Name:MOULTON, REGINE (MD)
Entity Type:Individual
Prefix:
First Name:REGINE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7809 LAUREL AVE
Mailing Address - Street 2:SUITE #11
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45243-2692
Mailing Address - Country:US
Mailing Address - Phone:513-561-7809
Mailing Address - Fax:513-272-4121
Practice Address - Street 1:7809 LAUREL AVE
Practice Address - Street 2:SUITE #11
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45243-2692
Practice Address - Country:US
Practice Address - Phone:513-561-7809
Practice Address - Fax:513-272-4121
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 037071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268857Medicaid
OHB77490Medicare UPIN
OH0268857Medicaid