Provider Demographics
NPI:1235294836
Name:MOLLENKOPF, WILLIAM HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HOWARD
Last Name:MOLLENKOPF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321
Mailing Address - Country:US
Mailing Address - Phone:970-565-2020
Mailing Address - Fax:970-565-3632
Practice Address - Street 1:140 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-0820
Practice Address - Country:US
Practice Address - Phone:970-565-2020
Practice Address - Fax:970-565-3632
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08009045Medicaid
CO0779800001Medicare NSC
COCF6713Medicare PIN
COU19559Medicare UPIN
COF6713Medicare ID - Type Unspecified