Healthcare Provider Details

I. General information

NPI: 1245869726
Provider Name (Legal Business Name): ANDREW MOULTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL, MSC 8208-0016-01
ST. LOUIS MO
63110
US

IV. Provider business mailing address

1 CHILDRENS PL, MSC 8208-0016-01
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2527
  • Fax: 314-747-8880
Mailing address:
  • Phone: 314-454-2527
  • Fax: 314-747-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2023011017
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberW6556
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: