Provider Demographics
NPI:1881859908
Name:MOLOCK-HEROLD, KELLY (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOLOCK-HEROLD
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 1:1103 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3619
Mailing Address - Country:US
Mailing Address - Phone:215-977-7700
Mailing Address - Fax:215-977-7105
Practice Address - Street 1:1103 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-3619
Practice Address - Country:US
Practice Address - Phone:215-977-7700
Practice Address - Fax:215-977-7105
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00615800152W00000X
PAOEG002162152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist