Healthcare Provider Details

I. General information

NPI: 1366499964
Provider Name (Legal Business Name): MARC A. MOLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 86TH ST
URBANDALE IA
50322-4201
US

IV. Provider business mailing address

2901 86TH ST
URBANDALE IA
50322-4201
US

V. Phone/Fax

Practice location:
  • Phone: 515-276-3406
  • Fax: 515-276-5141
Mailing address:
  • Phone: 515-276-3406
  • Fax: 515-276-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47097
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35723
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: