Provider Demographics
NPI:1023291713
Name:MOULTON, JAMES R II (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:MOULTON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:R
Other - Last Name:MOULTON
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2069 TERON TRACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-8716
Mailing Address - Country:US
Mailing Address - Phone:770-995-9100
Mailing Address - Fax:770-822-9444
Practice Address - Street 1:2069 TERON TRCE
Practice Address - Street 2:SUITE 100
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1665
Practice Address - Country:US
Practice Address - Phone:770-995-9100
Practice Address - Fax:770-822-9444
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043436207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309499OtherWELLCARE MEDICAID
GA5554055OtherAETNA
GA4804710OtherCIGNA
GA000750362BMedicaid
GAF73020Medicare UPIN
GA000750362BMedicaid