Provider Demographics
NPI:1073546636
Name:MOLK, IAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:J
Last Name:MOLK
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 1:4 ETHEL RD
Mailing Address - Street 2:SUITE 406A
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2841
Mailing Address - Country:US
Mailing Address - Phone:732-287-2888
Mailing Address - Fax:732-287-1176
Practice Address - Street 1:4 ETHEL RD STE 406A
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2841
Practice Address - Country:US
Practice Address - Phone:732-287-2888
Practice Address - Fax:732-287-1176
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0462510174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ449655Medicare ID - Type Unspecified
NJC54967Medicare UPIN