Provider Demographics
NPI:1760486112
Name:DODSON, MOLLIE (MD)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:DODSON
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 1:705 HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1008
Mailing Address - Country:US
Mailing Address - Phone:931-739-0048
Mailing Address - Fax:931-739-0047
Practice Address - Street 1:705 HOWELL ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1008
Practice Address - Country:US
Practice Address - Phone:931-739-0048
Practice Address - Fax:931-739-0047
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4116258Medicaid
TN3895284Medicare PIN
TN4116258Medicaid