Provider Demographics
NPI:1700958253
Name:MOLDREM, AMY WALTRIP (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WALTRIP
Last Name:MOLDREM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5298 SOCIALVILLE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9302
Mailing Address - Country:US
Mailing Address - Phone:513-770-4212
Mailing Address - Fax:513-770-4213
Practice Address - Street 1:7502 STATE RD STE 1180
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2800
Practice Address - Country:US
Practice Address - Phone:513-924-8535
Practice Address - Fax:513-624-2956
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35128160208600000X
OH35.128160208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH490720Medicare PIN
OHH490720Medicare PIN