Provider Demographics
NPI:1073773867
Name:WARTHAN, MOLLY MAE (MD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MAE
Last Name:WARTHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 EDWARDS RANCH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4131
Mailing Address - Country:US
Mailing Address - Phone:817-923-8220
Mailing Address - Fax:817-923-9004
Practice Address - Street 1:5751 EDWARDS RANCH RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4131
Practice Address - Country:US
Practice Address - Phone:817-923-8220
Practice Address - Fax:817-923-9004
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106298207N00000X
DCMD038210207N00000X
TXN2335207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021644T97Medicare Oscar/Certification
TXTXB130433Medicare Oscar/Certification