Basic Information
| Provider Information | |||||||||
| NPI: | 1396740742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430166102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145446155 | ||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 NIKE DR | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430269813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145336810 | ||||||||
| FaxNumber: | 6147779032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/29/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35085301 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2580130 | 05 | OH | MEDICAID |