Healthcare Provider Details

I. General information

NPI: 1558397489
Provider Name (Legal Business Name): MICHAEL LOWELL MOULTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 FOUNDERS PARK DR E
SPRINGDALE AR
72762-6314
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745-0550
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-2440
  • Fax: 479-463-2465
Mailing address:
  • Phone: 479-463-7775
  • Fax: 479-463-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberE-4391
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: