Healthcare Provider Details

I. General information

NPI: 1235294836
Provider Name (Legal Business Name): WILLIAM HOWARD MOLLENKOPF OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N MARKET ST
CORTEZ CO
81321-0820
US

IV. Provider business mailing address

PO BOX 820
CORTEZ CO
81321
US

V. Phone/Fax

Practice location:
  • Phone: 970-565-2020
  • Fax: 970-565-3632
Mailing address:
  • Phone: 970-565-2020
  • Fax: 970-565-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number904
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: