Provider Demographics
NPI:1518135649
Name:PAUL B. MOLL, O.D. LLC
Entity Type:Organization
Organization Name:PAUL B. MOLL, O.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:MOLL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-466-2070
Mailing Address - Street 1:828 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-5126
Mailing Address - Country:US
Mailing Address - Phone:772-466-2070
Mailing Address - Fax:
Practice Address - Street 1:828 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5126
Practice Address - Country:US
Practice Address - Phone:772-466-2070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2300Medicare PIN
FL4632990001Medicare NSC