1598005175 NPI number — ARABIA DIVINE MOLLETTE M.D.

Table of content: ARABIA DIVINE MOLLETTE M.D. (NPI 1598005175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598005175 NPI number — ARABIA DIVINE MOLLETTE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLLETTE
Provider First Name:
ARABIA
Provider Middle Name:
DIVINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOLLETTE
Provider Other First Name:
ARABIA
Provider Other Middle Name:
DEVINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1598005175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 BROADWAY
Provider Second Line Business Mailing Address:
DEPARTMENT OF MANAGED CARE, ROOM 2B-230
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11206-5317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-630-3020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 LYONS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07112-2027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-926-6671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  281186-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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