MEDICARE: DAVID L MOULTON M.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	2084F0202X	Forensic Psychiatry Physician	8303246-1205	UT

General Provider Information

NPI Number	:	1558332353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID L MOULTON M.D.

Provider Business Mailing Address
First Line	:	501 S CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1222
Country	:	US
Telephone Number	:	801-583-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 S CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1222
Country	:	US
Telephone Number	:	801-583-2500
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	11/08/2021

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