Provider Demographics
NPI:1609903848
Name:MOLAMPHY, MICHAEL JAMES (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MOLAMPHY
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 1:1746 GRAND CANAL BLVD STE 15
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8111
Mailing Address - Country:US
Mailing Address - Phone:209-957-2110
Mailing Address - Fax:209-472-9522
Practice Address - Street 1:1746 GRAND CANAL BLVD STE 15
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8111
Practice Address - Country:US
Practice Address - Phone:209-957-2110
Practice Address - Fax:209-472-9522
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6751 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0067510Medicaid
CASD0067510Medicaid