MEDICARE: DR. JASON HUGH MOULTON O.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	152W00000X	Optometrist	1452	AZ

General Provider Information

NPI Number	:	1841238565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON HUGH MOULTON O.D.

Provider Business Mailing Address
First Line	:	1075 S IDAHO RD
Second Line	:	SUITE 105B
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85119-6496
Country	:	US
Telephone Number	:	480-380-5116
Fax Number	:	480-380-0791

Provider Business Practice Location Address
First Line	:	1075 S IDAHO RD
Second Line	:	SUITE 105B
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85119-6496
Country	:	US
Telephone Number	:	480-380-5116
Fax Number	:	480-380-0791

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	11/29/2016

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