MEDICARE: JOHN L MOULTON III PH 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	103T00000X	Psychologist	PSY20637	CA

General Provider Information

NPI Number	:	1285669200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN L MOULTON III PH D

Provider Business Mailing Address
First Line	:	P. O. BOX 1381
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 LAKE EARL DRIVE
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/08/2007

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