Provider Demographics
NPI:1871180372
Name:MOULTRY, ZEBEDEE
Entity Type:Individual
Prefix:
First Name:ZEBEDEE
Middle Name:
Last Name:MOULTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 HILBISH AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-2251
Mailing Address - Country:US
Mailing Address - Phone:330-328-3240
Mailing Address - Fax:
Practice Address - Street 1:540 HILBISH AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-2251
Practice Address - Country:US
Practice Address - Phone:330-328-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7718964Medicaid