Healthcare Provider Details

I. General information

NPI: 1669590543
Provider Name (Legal Business Name): MARK STEVEN MOLITOR JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E CAMBRIDGE AVE SUITE #201
PHOENIX AZ
85006-1459
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-5561
  • Fax: 602-254-2185
Mailing address:
  • Phone: 602-933-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301088111
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number47558
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number7947793-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number4301088111
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number47558
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number47558
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: