Provider Demographics
NPI:1023000395
Name:MOLLOY, THOMAS ALEXIS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALEXIS
Last Name:MOLLOY
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 1:2241 LLOYD CTR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1315
Mailing Address - Country:US
Mailing Address - Phone:253-272-7777
Mailing Address - Fax:253-426-4142
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:253-272-7777
Practice Address - Fax:253-426-4142
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030543208G00000X
MTMED-PHYS-LIC-58617208G00000X
ORMD16887208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8155699Medicaid
WA8155694Medicaid
OR014667Medicaid
OR115783Medicare ID - Type UnspecifiedSALEM
WA8155694Medicaid
OR014667Medicaid
ORD00002Medicare UPIN
WAAB37912Medicare ID - Type UnspecifiedVANCOUVER