Provider Demographics
NPI:1790001220
Name:MOLLERE, OLIVER
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:
Last Name:MOLLERE
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4225 LAPALCO BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4338
Practice Address - Country:US
Practice Address - Phone:504-371-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.205723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2107178Medicaid
LA06771046Medicaid
LA249683YH3UMedicare PIN