Provider Demographics
NPI:1821434382
Name:MOLLECK, MEGAN ELIZABETH (MD)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:MOLLECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MEGAN
Other - Middle Name:ELIZABETH
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8300 CONSTITUTION AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-291-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-0571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine