Provider Demographics
NPI:1982784823
Name:MACCORMACK, MOLLIE A (MD)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:A
Last Name:MACCORMACK
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:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:17 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3956
Practice Address - Country:US
Practice Address - Phone:603-883-8311
Practice Address - Fax:603-883-8317
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215758207N00000X, 207ND0101X, 207NS0135X
NH17581207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110037844AMedicaid
MASX2696Medicare PIN
MAI09287Medicare UPIN
MAA3698101Medicare PIN