Healthcare Provider Details

I. General information

NPI: 1265420582
Provider Name (Legal Business Name): JEFFERSON EADDY CARTER MOULDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19735 GERMANTOWN RD STE 255
GERMANTOWN MD
20874-1219
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 240-912-7645
  • Fax: 301-593-9035
Mailing address:
  • Phone: 855-963-2100
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number21925
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0101052934
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD50244
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: