Provider Demographics
NPI:1174605166
Name:MOULTON, KRIEGH P (MD)
Entity type:Individual
Prefix:
First Name:KRIEGH
Middle Name:P
Last Name:MOULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-573-6166
Mailing Address - Fax:707-573-6165
Practice Address - Street 1:3536 MENDOCINO AVE STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-573-6166
Practice Address - Fax:707-573-6165
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG159991207RC0000X, 207RC0001X
IL036-082099207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082099Medicaid
IL060015544OtherRAILROAD
IL060015544OtherRAILROAD
ILL66763Medicare ID - Type Unspecified