Provider Demographics
NPI:1003067745
Name:MOLES, JEREMIAH (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:MOLES
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 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG 3 SUITE 101
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-464-3353
Mailing Address - Fax:619-464-6720
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG 3 SUITE 101
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-464-3353
Practice Address - Fax:619-464-6720
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112009207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology