1891707584 NPI number — KIMBERLY S MOLTER OD

Table of content: KIMBERLY S MOLTER OD (NPI 1891707584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891707584 NPI number — KIMBERLY S MOLTER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLTER
Provider First Name:
KIMBERLY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1891707584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALKASKA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49646-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-258-9781
Provider Business Mailing Address Fax Number:
231-258-0616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 BRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLEVOIX
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49720-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-547-7800
Provider Business Practice Location Address Fax Number:
231-547-7874
Provider Enumeration Date:
08/12/2006

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: 152W00000X , with the licence number:  4901003200 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0800300002 . This is a "DMEPOS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1891707584 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900AS10210 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MI3200 . This is a "EYEMED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: KM003200 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: OPC2298 . This is a "FLORIDA LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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