Basic Information
Provider Information | |||||||||
NPI: | 1881078970 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLITORIS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | ANDREW | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 WESCOTT DR STE 303 | ||||||||
Address2: |   | ||||||||
City: | FLEMINGTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 088224600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9087886449 | ||||||||
FaxNumber: | 9087886668 | ||||||||
Practice Location | |||||||||
Address1: | 1100 WESCOTT DR STE 303 | ||||||||
Address2: |   | ||||||||
City: | FLEMINGTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 088224600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9087886449 | ||||||||
FaxNumber: | 9087886668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2015 | ||||||||
LastUpdateDate: | 08/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC006688 | PA | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 25MD00342700 | NJ | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.