Provider Demographics
NPI:1710013263
Name:DUTRA, MOLLI A (MD)
Entity Type:Individual
Prefix:
First Name:MOLLI
Middle Name:A
Last Name:DUTRA
Suffix:
Gender:F
Credentials:MD
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:3425 ENSIGN RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5425
Practice Address - Country:US
Practice Address - Phone:360-923-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023026Medicaid
WAGAB13303Medicare PIN
WAG8872302Medicare PIN
WAU78568Medicare UPIN
WAGAB13301Medicare PIN
WAGAB13304Medicare PIN
WA2023026Medicaid
WAGAB13603Medicare PIN