Provider Demographics
NPI:1043243009
Name:CAMACHO, MOLLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20 ZELLER XING APT 207
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9468
Mailing Address - Country:US
Mailing Address - Phone:319-530-5468
Mailing Address - Fax:319-625-3032
Practice Address - Street 1:2590 HOLIDAY RD STE 10
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2815
Practice Address - Country:US
Practice Address - Phone:319-625-3030
Practice Address - Fax:319-625-3032
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA03522208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA33606OtherWELLMARK BCBS
IA0429274Medicaid
IAF232553OtherMIDLANDS CHOICE
IAP00257946OtherRAILROAD MEDICARE
IAF232553OtherMIDLANDS CHOICE