Provider Demographics
NPI:1770040180
Name:MOLINA MORENO, JOSE ALFREDO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFREDO
Last Name:MOLINA MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 HARRISON PARK DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37341-9621
Mailing Address - Country:US
Mailing Address - Phone:423-344-7095
Mailing Address - Fax:423-344-7569
Practice Address - Street 1:6800 HARRISON PARK DR
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:TN
Practice Address - Zip Code:37341-9621
Practice Address - Country:US
Practice Address - Phone:423-344-7095
Practice Address - Fax:423-344-7569
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN64880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine