Provider Demographics
NPI:1073975629
Name:MOLDEN, BRENT MATTHEW (MD, PHD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:MATTHEW
Last Name:MOLDEN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W 11TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4108
Practice Address - Country:US
Practice Address - Phone:317-491-6000
Practice Address - Fax:317-491-6534
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087889A207ZC0500X, 207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program