Healthcare Provider Details

I. General information

NPI: 1033202593
Provider Name (Legal Business Name): ROCKWELL G MOULTON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 45TH AVE NE
SEATTLE WA
98115
US

IV. Provider business mailing address

PO BOX 25657
SEATTLE WA
98165
US

V. Phone/Fax

Practice location:
  • Phone: 206-522-6640
  • Fax: 206-527-0147
Mailing address:
  • Phone: 206-522-6640
  • Fax: 206-527-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO00000450
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: