Provider Demographics
NPI:1952663924
Name:MOLITERNO, COURTNEY (OD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MOLITERNO
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 1:8470 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BIRCH RUN
Mailing Address - State:MI
Mailing Address - Zip Code:48415-9461
Mailing Address - Country:US
Mailing Address - Phone:989-624-2020
Mailing Address - Fax:989-624-6257
Practice Address - Street 1:8470 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIRCH RUN
Practice Address - State:MI
Practice Address - Zip Code:48415-9704
Practice Address - Country:US
Practice Address - Phone:989-624-2020
Practice Address - Fax:989-624-6257
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004706152W00000X, 152WC0802X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
900G30405OtherBCBS
MI19526639OtherHEALTHPLUS
MI19526639OtherHEALTHPLUS