Provider Demographics
NPI:1366619132
Name:MOULTON, ALLYSON W (MD)
Entity type:Individual
Prefix:DR
First Name:ALLYSON
Middle Name:W
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4943
Mailing Address - Country:US
Mailing Address - Phone:479-709-7350
Mailing Address - Fax:479-709-7355
Practice Address - Street 1:2 MEDICAL PARK RD STE 306
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:803-256-2657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116020110208600000X
SCLL34981208600000X
ARE8287208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery