1720121684 NPI number — ALLEN R MOLLOY MD

Table of content: ALLEN R MOLLOY MD (NPI 1720121684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720121684 NPI number — ALLEN R MOLLOY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLLOY
Provider First Name:
ALLEN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720121684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 NW 56TH ST
Provider Second Line Business Mailing Address:
206
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-4479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-945-4740
Provider Business Mailing Address Fax Number:
405-945-4751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 NW 56TH ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73112-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-945-4740
Provider Business Practice Location Address Fax Number:
405-945-4751
Provider Enumeration Date:
02/14/2007

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: 2085R0202X , with the licence number:  22334 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 036163488 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 22334 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 249722912 . This is a "MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 248722910 . This is a "MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: P00974065 . This is a "MEDICARE RAILROAD (RALLC)" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200106970A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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