Provider Demographics
NPI:1326209131
Name:OMIZO, MOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:
Last Name:OMIZO
Suffix:
Gender:F
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0490
Mailing Address - Country:US
Mailing Address - Phone:541-388-3978
Mailing Address - Fax:541-278-8366
Practice Address - Street 1:2200 NE NEFF RD
Practice Address - Street 2:SUITE 302
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4283
Practice Address - Country:US
Practice Address - Phone:541-388-3978
Practice Address - Fax:541-278-8366
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD17366OtherSTATE LICENSE