Provider Demographics
NPI:1396893137
Name:MOULTON, PAULETTE (MD)
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
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 2503
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-7503
Mailing Address - Country:US
Mailing Address - Phone:734-241-4950
Mailing Address - Fax:734-243-4269
Practice Address - Street 1:2246 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162
Practice Address - Country:US
Practice Address - Phone:734-241-4950
Practice Address - Fax:734-243-4269
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042274207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4893843Medicaid
MI0705810691OtherBCBS OF MICHIGAN
MIA73456Medicare UPIN
MIOP16880001Medicare ID - Type Unspecified