Basic Information
| Provider Information | |||||||||
| NPI: | 1538294897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RN OTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664541 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 083026191RN | OR | N | Nursing Service Providers | Registered Nurse | 163WX0800X | 930064 | OR | N | Nursing Service Providers | Registered Nurse | Orthopedic | 374700000X | 930064 OT-SC | OR | Y | Nursing Service Related Providers | Technician |
ID Information
| ID | Type | State | Issuer | Description | 1407812365 | 01 | OR | GROUP NPI NUMBER | OTHER | 930635514 | 01 | OR | GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | MEDICARE GROUP PIN NUMBER | OTHER |