Healthcare Provider Details

I. General information

NPI: 1831459890
Provider Name (Legal Business Name): JONATHAN D MOULDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 WISHARD BLVD
INDIANAPOLIS IN
46202-2872
US

IV. Provider business mailing address

1040 WISHARD BLVD
INDIANAPOLIS IN
46202-2872
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-8893
  • Fax: 317-962-6722
Mailing address:
  • Phone: 317-962-8893
  • Fax: 317-962-6722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01075524A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: