Provider Demographics
NPI:1255330205
Name:MOULTON, PAUL RUSH (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:RUSH
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5309
Mailing Address - Country:US
Mailing Address - Phone:207-945-3619
Mailing Address - Fax:
Practice Address - Street 1:5 GROVE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5309
Practice Address - Country:US
Practice Address - Phone:207-945-3619
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012516207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB58117Medicare UPIN
MEMM2104Medicare ID - Type Unspecified