Provider Demographics
NPI:1669796223
Name:MOLLARD, BRETT JUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JUSTIN
Last Name:MOLLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD606462572085R0202X
MI43010981452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2058603Medicaid
WAG8953532Medicare PIN
WA2058603Medicaid
WAG8953531Medicare PIN
WAG8953529Medicare PIN