MEDICARE: DR. JOHN STEPHEN MOULTON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3280TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174628275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN STEPHEN MOULTON O.D.

Provider Business Mailing Address
First Line	:	721 LAKE VIEW DR
Second Line	:
City	:	CROWLEY
State	:	TX
Zip	:	76036-3957
Country	:	US
Telephone Number	:	817-426-4240
Fax Number	:	817-426-3654

Provider Business Practice Location Address
First Line	:	6300 OAKMONT BLVD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76132-2813
Country	:	US
Telephone Number	:	817-294-2010
Fax Number	:	817-294-2024

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/09/2007

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