Provider Demographics
NPI:1477658920
Name:MOLLENGARDEN, GARY ALEX (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALEX
Last Name:MOLLENGARDEN
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 1:985 9TH AVE SW STE 307
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-7809
Mailing Address - Country:US
Mailing Address - Phone:205-481-7384
Mailing Address - Fax:205-481-7389
Practice Address - Street 1:985 9TH AVE SW STE 307
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-7809
Practice Address - Country:US
Practice Address - Phone:205-481-7384
Practice Address - Fax:205-481-7389
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00012096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000081606Medicaid
AL051081606Medicare ID - Type Unspecified
AL000081606Medicaid