Provider Demographics
NPI:1811914351
Name:MOLACEK, KIMBERLY ANN (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:MOLACEK
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353
Mailing Address - Country:US
Mailing Address - Phone:320-983-3434
Mailing Address - Fax:320-983-6280
Practice Address - Street 1:132 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353
Practice Address - Country:US
Practice Address - Phone:320-983-3434
Practice Address - Fax:320-983-6280
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN236325900Medicaid
MN236325900Medicaid
MN410001301Medicare ID - Type Unspecified