Provider Demographics
NPI:1235768805
Name:MOLLINEDA, JONATHAN LAZARO (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LAZARO
Last Name:MOLLINEDA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 NW 49TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-1608
Mailing Address - Country:US
Mailing Address - Phone:754-296-5900
Mailing Address - Fax:
Practice Address - Street 1:2951 NW 49TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1608
Practice Address - Country:US
Practice Address - Phone:754-296-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4362213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program