Basic Information
| Provider Information | |||||||||
| NPI: | 1215013156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 28TH ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111052702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187212780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2432 GRAND CONCOURSE | ||||||||
| Address2: | POE CLINIC | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185797337 | ||||||||
| FaxNumber: | 7188177904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | 168593 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 01232099 | 05 | NY | MEDICAID |