Provider Demographics
NPI:1891758850
Name:MOULTON, MARK JR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JR
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1400 MERCY DR.
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1878
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-733-5212
Practice Address - Street 1:1400 MERCY DR.
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1878
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-5212
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301075708207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4238876Medicaid
MI4301075708OtherSTATE LICENSE
MI4301075708OtherSTATE LICENSE
MIH18276Medicare UPIN