Provider Demographics
NPI:1750705836
Name:MOLDAWSKY, MAREK R JR (MED, EDS)
Entity type:Individual
Prefix:
First Name:MAREK
Middle Name:R
Last Name:MOLDAWSKY
Suffix:JR
Gender:M
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 CHIQUITA BLVD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6321
Mailing Address - Country:US
Mailing Address - Phone:239-834-9333
Mailing Address - Fax:
Practice Address - Street 1:4706 CHIQUITA BLVD S
Practice Address - Street 2:SUITE 200
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6321
Practice Address - Country:US
Practice Address - Phone:239-834-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS #1290103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool