Provider Demographics
NPI:1235147331
Name:MOLITOR, JERRY A (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:A
Last Name:MOLITOR
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 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE, CLINIC 6A
Practice Address - Street 2:UMP MEDICINE SPECIALTIES CLINIC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-884-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00035031207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD9155WOtherALASKA MEDICAID
WA6118MOOtherBLUE SHIELD
WAUS2338018OtherAETNA/USHC SPECIALIST
660003069OtherRAILROAD MEDICARE
WA805452300OtherIDAHO MEDICAID
WA8256877Medicaid
WA0039583OtherLABOR & INDUSTRY
WA8808801Medicare PIN
WA0039583OtherLABOR & INDUSTRY
WAUS2338018OtherAETNA/USHC SPECIALIST
H06155Medicare UPIN