Provider Demographics
NPI:1366499964
Name:MOLIS, MARC A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:MOLIS
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 1:2901 86TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4201
Mailing Address - Country:US
Mailing Address - Phone:515-276-3406
Mailing Address - Fax:515-276-5141
Practice Address - Street 1:2901 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4201
Practice Address - Country:US
Practice Address - Phone:515-276-3406
Practice Address - Fax:515-276-5141
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47097207Q00000X
IA35723207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400370Medicaid
IA1366499964Medicaid
WI34847600Medicaid
IAP01169442OtherRR MEDICARE
IA20238002Medicare PIN
I15966Medicare UPIN
IA0400370Medicaid
IA719260389Medicare PIN