Provider Demographics
NPI:1376646372
Name:WHARTON, MOLLY MARIE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MARIE
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19400 NW EVERGREEN PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124
Mailing Address - Country:US
Mailing Address - Phone:503-690-5015
Mailing Address - Fax:503-690-5034
Practice Address - Street 1:19400 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7031
Practice Address - Country:US
Practice Address - Phone:503-690-5015
Practice Address - Fax:503-690-5034
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1814T152W00000X
WAOD00003969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist