MEDICARE: DR. DARREN KEITH MOLLICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician	217820-4	NY
2	207N00000X	Dermatology Physician	217820	NY
3	207NP0225X	Pediatric Dermatology Physician	217820	NY
4	207NS0135X	Procedural Dermatology Physician	217820	NY

General Provider Information

NPI Number	:	1225012552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARREN KEITH MOLLICK MD

Provider Business Mailing Address
First Line	:	175 JERICHO TPKE
Second Line	:	SUITE 320
City	:	SYOSSET
State	:	NY
Zip	:	11791-4532
Country	:	US
Telephone Number	:	516-921-6780
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 JERICHO TPKE
Second Line	:	SUITE 320
City	:	SYOSSET
State	:	NY
Zip	:	11791-4532
Country	:	US
Telephone Number	:	516-921-6780
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	10/02/2007

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