Provider Demographics
NPI:1477605111
Name:MOLL, MARK J (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:MOLL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-4339
Mailing Address - Country:US
Mailing Address - Phone:863-467-8382
Mailing Address - Fax:
Practice Address - Street 1:204 S PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-4339
Practice Address - Country:US
Practice Address - Phone:863-467-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3370152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL651099741Medicaid
FL651099741Medicaid
FLK2714Medicare ID - Type UnspecifiedMEDICARE