Provider Demographics
NPI:1578761391
Name:MOLINA, MARCO R (MD)
Entity Type:Individual
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First Name:MARCO
Middle Name:R
Last Name:MOLINA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:RADIOLOGY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2803
Practice Address - Country:US
Practice Address - Phone:860-679-2784
Practice Address - Fax:860-679-4126
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2022-09-28
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Provider Licenses
StateLicense IDTaxonomies
CT0482712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1578761391Medicaid