Provider Demographics
NPI:1629233895
Name:MOLK, GARY IAN (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:IAN
Last Name:MOLK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16243
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:AK
Mailing Address - Zip Code:99716-0243
Mailing Address - Country:US
Mailing Address - Phone:907-987-4390
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST STE 105
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-459-3545
Practice Address - Fax:907-328-0474
Is Sole Proprietor?:No
Enumeration Date:2008-07-27
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8512A207XX0801X, 207X00000X
AK107960207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1647591Medicaid
WY1350OtherWY LICENSE