Basic Information
| Provider Information | |||||||||
| NPI: | 1528040631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOEFLICH | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 821350 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986820030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032835220 | ||||||||
| FaxNumber: | 5032834527 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 NE HOYT ST | ||||||||
| Address2: | SUITE 353 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032302833 | ||||||||
| FaxNumber: | 5032328223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
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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 | 208100000X | MD14908 | OR | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 101808 | 05 | OR | MEDICAID |