Basic Information
Provider Information | |||||||||
NPI: | 1417020074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLODECKI | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7200 CORPORATE CENTER DR | ||||||||
Address2: | #600 | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331261200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055002000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 228 W ALEXANDER ST | ||||||||
Address2: |   | ||||||||
City: | PLANT CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 335637157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137545480 | ||||||||
FaxNumber: | 8137542251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 12/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9101062 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.