Provider Demographics
NPI:1447244025
Name:MOLENICH, SHIRLEY A (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:MOLENICH
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 1:1307 8TH AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-920-0900
Mailing Address - Fax:817-920-0969
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:STE 301
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-920-0900
Practice Address - Fax:817-920-0969
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE33792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82160YOtherBCBS OF TX
TX133840203Medicaid
TX8C1347Medicare PIN
B24958Medicare UPIN