MEDICARE: MARLENE S 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	207R00000X	Internal Medicine Physician	ME94816	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548396047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE S MOULTON M.D.

Provider Business Mailing Address
First Line	:	13421 PARKER COMMONS BLVD
Second Line	:	STE 101
City	:	FORT MYERS
State	:	FL
Zip	:	33912-2076
Country	:	US
Telephone Number	:	239-985-2600
Fax Number	:	239-985-0103

Provider Business Practice Location Address
First Line	:	14090 METROPOLIS AVE
Second Line	:	SUITE 102
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4450
Country	:	US
Telephone Number	:	239-985-2600
Fax Number	:	239-985-0103

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	06/02/2016

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