Provider Demographics
NPI:1366470866
Name:MOLESWORTH, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOLESWORTH
Suffix:
Gender:M
Credentials:
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 730
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21705-0730
Mailing Address - Country:US
Mailing Address - Phone:301-631-9191
Mailing Address - Fax:301-631-1002
Practice Address - Street 1:400 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4506
Practice Address - Country:US
Practice Address - Phone:240-566-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0040539207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD782001100Medicaid
MD782001100Medicaid
MDH733LR29Medicare PIN
MDH733Medicare ID - Type UnspecifiedMEDICARE GRP #