Healthcare Provider Details

I. General information

NPI: 1538282942
Provider Name (Legal Business Name): JEREMY DAVID MOLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

IV. Provider business mailing address

4979 ODELL ST
SAINT LOUIS MO
63139-1009
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-7827
  • Fax:
Mailing address:
  • Phone: 314-330-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01063842A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: