Basic Information
Provider Information | |||||||||
NPI: | 1861585887 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLL | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | MARTIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 960 PENINSULA ST | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930013954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056525018 | ||||||||
FaxNumber: | 8056500474 | ||||||||
Practice Location | |||||||||
Address1: | 147 N BRENT SREET | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 93003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056525011 | ||||||||
FaxNumber: | 8055853007 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
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 | 146D00000X | G68497 | CA | Y |   | Emergency Medical Service Providers | Personal Emergency Response Attendant |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ53994Z | 01 | CA | BLUE SHIELD | OTHER | ZZT40394F | 05 | CA |   | MEDICAID | G68497 | 01 | CA | LICENSE NUMBER | OTHER | HSC30394F | 05 | CA |   | MEDICAID | 050394 | 01 | CA | BLUE CROSS | OTHER | ZZZA56032 | 01 | CA | BLUE SHIELD | OTHER |