Provider Demographics
NPI:1003296724
Name:MCCORMICK, MOLLY M (DO)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:M
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:M
Other - Last Name:LUNSTRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:708 E WYTHE CREEK CT STE 103
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5005
Practice Address - Country:US
Practice Address - Phone:208-922-5130
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1008207Q00000X
IDMRO-1478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1003296724Medicaid