Provider Demographics
NPI:1457378978
Name:MOELL, ANN T (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:T
Last Name:MOELL
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 1:359 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4563
Mailing Address - Country:US
Mailing Address - Phone:937-228-4492
Mailing Address - Fax:
Practice Address - Street 1:359 FOREST AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4563
Practice Address - Country:US
Practice Address - Phone:937-228-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-060654 M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0966969Medicaid
0728844Medicare PIN
OH0966969Medicaid