Provider Demographics
NPI:1265420582
Name:MOULDS, JEFFERSON EADDY CARTER (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:EADDY CARTER
Last Name:MOULDS
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:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-0430
Mailing Address - Country:US
Mailing Address - Phone:757-302-2600
Mailing Address - Fax:757-789-0631
Practice Address - Street 1:20480 MARKET STREET
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417-0430
Practice Address - Country:US
Practice Address - Phone:757-302-2600
Practice Address - Fax:757-789-0631
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD502442085R0001X
DC219252085R0001X
VA01010529342085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1265420582Medicaid
VA2176156OtherMAMSI/UNITED HEALTHCARE
VA342750OtherANTHEM BCBS
VA9558847OtherCIGNA
VA342750OtherANTHEM BCBS
VA1265420582Medicaid
VA003312M67Medicare PIN