Basic Information
| Provider Information | |||||||||
| NPI: | 1003201617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLANAZAR | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | KIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | 2 MALONEY BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156627366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | 2 MALONEY BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156627366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD467873 | PA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.