Provider Demographics
NPI:1891707584
Name:MOLTER, KIMBERLY S (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:MOLTER
Suffix:
Gender:F
Credentials:OD
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 2027
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2027
Mailing Address - Country:US
Mailing Address - Phone:231-258-9781
Mailing Address - Fax:231-258-0616
Practice Address - Street 1:1008 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1602
Practice Address - Country:US
Practice Address - Phone:231-547-7800
Practice Address - Fax:231-547-7874
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0800300002OtherDMEPOS
MI1891707584Medicaid
MI900AS10210OtherBLUE CROSS BLUE SHIELD
MIMI3200OtherEYEMED
MIKM003200OtherSTATE LICENSE
FLOPC2298OtherFLORIDA LICENSE NUMBER
MI0800300002OtherDMEPOS
FLOPC2298OtherFLORIDA LICENSE NUMBER
MIOM39690002Medicare ID - Type Unspecified