MEDICARE: JONATHAN S. MOULTON MD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	35-05-1867-M	OH
2	2085N0700X	Neuroradiology Physician	35.051867	OH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	300033840	OTHER	OH	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	655268	OTHER	OH	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1620980	OTHER	OH	UHC
7	000000014486	OTHER	OH	ANTHEM
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1457391526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN S. MOULTON MD

Provider Business Mailing Address
First Line	:	PO BOX 636256 CENTRAL CREDENTIALING
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-6256
Country	:	US
Telephone Number	:	513-245-3107
Fax Number	:	513-585-5511

Provider Business Practice Location Address
First Line	:	234 GOODMAN ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-2364
Country	:	US
Telephone Number	:	513-584-7355
Fax Number	:	513-584-0431

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	02/20/2018

3188 BELLEVUE AVE
CINCINNATI, OH
45219-2364

Practice Phone: 513-584-4391
Practice Fax: 513-584-0431