Provider Demographics
NPI:1285671131
Name:MOLL, JUSTIN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:S
Last Name:MOLL
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 1:525 VERDAE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4021
Mailing Address - Country:US
Mailing Address - Phone:864-272-0388
Mailing Address - Fax:864-213-9237
Practice Address - Street 1:525 VERDAE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4021
Practice Address - Country:US
Practice Address - Phone:864-272-0388
Practice Address - Fax:864-213-9237
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23856208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6926060OtherCIGNA
SC7129677OtherAETNA
SC238567Medicaid
SC576007863102OtherBCBS OF SC
SC576007863103OtherBLUE CHOICE OF SC
SC7129677OtherAETNA
SCAA09213640Medicare ID - Type UnspecifiedMEDICARE ID