Healthcare Provider Details

I. General information

NPI: 1861704181
Provider Name (Legal Business Name): IRIDA MOLLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IRIDA HASALLA

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GRANDVIEW AVE
WATERBURY CT
06708-2505
US

IV. Provider business mailing address

793 EASTERN BYP SUITE 201
RICHMOND KY
40475-2422
US

V. Phone/Fax

Practice location:
  • Phone: 203-574-4187
  • Fax: 203-575-2153
Mailing address:
  • Phone: 859-624-6560
  • Fax: 859-624-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number48240
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48240
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number56841
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: