Provider Demographics
NPI:1942307053
Name:MOLENAAR, BRANT T (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANT
Middle Name:T
Last Name:MOLENAAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3546 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438
Mailing Address - Country:US
Mailing Address - Phone:708-474-0078
Mailing Address - Fax:708-474-0141
Practice Address - Street 1:3546 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438
Practice Address - Country:US
Practice Address - Phone:708-474-0078
Practice Address - Fax:708-474-0141
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL468622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U46750Medicare UPIN