Provider Demographics
NPI:1114606670
Name:MOLTER, CRISTIN A
Entity Type:Individual
Prefix:
First Name:CRISTIN
Middle Name:A
Last Name:MOLTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 GARY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4272
Mailing Address - Country:US
Mailing Address - Phone:614-629-4411
Mailing Address - Fax:
Practice Address - Street 1:1072 GARY DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4272
Practice Address - Country:US
Practice Address - Phone:614-629-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTP526496172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1487333951Medicaid