Provider Demographics
NPI:1376746545
Name:MOULTRIE, ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:MOULTRIE
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 1:6556 MEADOWFIELD CT
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6879
Mailing Address - Country:US
Mailing Address - Phone:443-571-3567
Mailing Address - Fax:
Practice Address - Street 1:7555 WATERLOO RD
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:MD
Practice Address - Zip Code:20794-9783
Practice Address - Country:US
Practice Address - Phone:410-799-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068511208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI00789Medicare UPIN