Provider Demographics
NPI:1720175995
Name:MOULTRIE, AIDA (OD)
Entity Type:Individual
Prefix:DR
First Name:AIDA
Middle Name:
Last Name:MOULTRIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 GOSS ROAD
Mailing Address - Street 2:FOX ARMY HEALTH CENTER ATTN:MCXW-NOPS
Mailing Address - City:REDSTONE ARSENAL
Mailing Address - State:AL
Mailing Address - Zip Code:35809-7000
Mailing Address - Country:US
Mailing Address - Phone:256-955-6492
Mailing Address - Fax:256-842-2019
Practice Address - Street 1:4100 GOSS RD.
Practice Address - Street 2:FOX ARMY HEALTH CENTER/OPT
Practice Address - City:REDSTONE ARSENAL
Practice Address - State:AL
Practice Address - Zip Code:35809-7000
Practice Address - Country:US
Practice Address - Phone:256-955-8888
Practice Address - Fax:256-955-6060
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-519-TA-687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALVAD 000Medicare UPIN