Provider Demographics
NPI:1114125903
Name:MENTZER, MOLLY E (DO)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:E
Last Name:MENTZER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3016
Mailing Address - Country:US
Mailing Address - Phone:484-565-8550
Mailing Address - Fax:
Practice Address - Street 1:25 DEGRANDPRE WAY
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6449
Practice Address - Country:US
Practice Address - Phone:518-563-3260
Practice Address - Fax:518-561-2877
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275860-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03949951Medicaid
PA23-2359401OtherMLHC TAX IDENTIFICATION
NYJ400175781Medicare PIN
PA115210HK1Medicare PIN