Provider Demographics
NPI:1679624308
Name:MOLL, PAUL BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BRADLEY
Last Name:MOLL
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 1:828 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:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU58383Medicare UPIN
FLK2300Medicare ID - Type UnspecifiedMEDICARE