Basic Information
| Provider Information | |||||||||
| NPI: | 1114125903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENTZER | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 WILDFLOWER LN | ||||||||
| Address2: | |||||||||
| City: | MORRISONVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129623016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845658550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 DEGRANDPRE WAY | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129016449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185633260 | ||||||||
| FaxNumber: | 5185612877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 275860-1 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 03949951 | 05 | NY | MEDICAID | 23-2359401 | 01 | PA | MLHC TAX IDENTIFICATION | OTHER |