Basic Information
| Provider Information | |||||||||
| NPI: | 1639639859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLL | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOL | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 81 N MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016625701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 UPPER CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210144324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436431500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2019 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 11912736-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | D94665 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.