Healthcare Provider Details

I. General information

NPI: 1376746545
Provider Name (Legal Business Name): ANDREW MOULTRIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7555 WATERLOO RD
JESSUP MD
20794-9783
US

IV. Provider business mailing address

6556 MEADOWFIELD CT
ELKRIDGE MD
21075-6879
US

V. Phone/Fax

Practice location:
  • Phone: 410-799-3400
  • Fax:
Mailing address:
  • Phone: 443-571-3567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD0068511
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: