Provider Demographics
NPI:1922056514
Name:MOLLOT, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MOLLOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 94670
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-4670
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-384-6793
Practice Address - Street 1:1023 N MOUND ST STE B
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4453
Practice Address - Country:US
Practice Address - Phone:936-569-2590
Practice Address - Fax:936-569-2592
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3164207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA23502Medicare UPIN