Provider Demographics
NPI:1891926176
Name:MOLIK, MACIEJ STANISLAW (PT)
Entity Type:Individual
Prefix:
First Name:MACIEJ
Middle Name:STANISLAW
Last Name:MOLIK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 NEWPORT DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 N WICKHAM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8628
Practice Address - Country:US
Practice Address - Phone:321-514-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 27353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M400052236Medicare PIN