Provider Demographics
NPI:1790773802
Name:MOULLET, DANIEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:MOULLET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1200 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3354
Mailing Address - Country:US
Mailing Address - Phone:509-684-3701
Mailing Address - Fax:509-684-5817
Practice Address - Street 1:107 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2634
Practice Address - Country:US
Practice Address - Phone:406-676-4441
Practice Address - Fax:406-676-0835
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00034152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
114507OtherL & I
WA8208357Medicaid
G51849Medicare UPIN