MEDICARE: PAUL RUSH MOULTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	012516	ME

General Provider Information

NPI Number	:	1255330205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL RUSH MOULTON M.D.

Provider Business Mailing Address
First Line	:	5 GROVE ST
Second Line	:
City	:	BANGOR
State	:	ME
Zip	:	04401-5309
Country	:	US
Telephone Number	:	207-945-3619
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 GROVE ST
Second Line	:
City	:	BANGOR
State	:	ME
Zip	:	04401-5309
Country	:	US
Telephone Number	:	207-945-3619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/09/2007

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