Healthcare Provider Details

I. General information

NPI: 1831209261
Provider Name (Legal Business Name): MATTHEW MOLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W CENTRAL AVE
EL DORADO KS
67042
US

IV. Provider business mailing address

1518 N TERHUNE ST
WICHITA KS
67230-7243
US

V. Phone/Fax

Practice location:
  • Phone: 316-322-4500
  • Fax:
Mailing address:
  • Phone: 316-371-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31922
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31922
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: