Healthcare Provider Details

I. General information

NPI: 1225253792
Provider Name (Legal Business Name): CHARLES THOMAS MOLTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 SABATTUS ST
LEWISTON ME
04240-3831
US

IV. Provider business mailing address

685 SABATTUS ST
LEWISTON ME
04240-3831
US

V. Phone/Fax

Practice location:
  • Phone: 207-784-1699
  • Fax: 207-784-7554
Mailing address:
  • Phone: 207-784-1699
  • Fax: 207-784-7554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD433419
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD28543
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number35053258
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: