Provider Demographics
NPI:1881706463
Name:MOLLMAN, HENRY DENNIS (MD PHD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:DENNIS
Last Name:MOLLMAN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:H
Other - Middle Name:DENNIS
Other - Last Name:MOLLMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD PHD
Mailing Address - Street 1:3635 VISTA AVE.,
Mailing Address - Street 2:5 FDT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-577-8715
Mailing Address - Fax:314-577-8720
Practice Address - Street 1:3655 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-577-8715
Practice Address - Fax:314-577-8720
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121197207T00000X
MOR7G01207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121197Medicaid
WI30515300Medicaid
MO1881706463Medicaid
WI000639285Medicare ID - Type Unspecified
A13600Medicare UPIN
WI30515300Medicaid
MO1881706463Medicaid
MO152360162Medicare UPIN