Healthcare Provider Details

I. General information

NPI: 1710479761
Provider Name (Legal Business Name): MOLLIE WETSTEIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N 7 HILLS RD STE 220
O FALLON IL
62269-4111
US

IV. Provider business mailing address

415 W COLUMBIA ST STE 110
EVANSVILLE IN
47710-1656
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-6181
  • Fax: 618-624-7172
Mailing address:
  • Phone: 812-450-3363
  • Fax: 812-450-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01084278A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11019961A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036177195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: