Healthcare Provider Details

I. General information

NPI: 1447631353
Provider Name (Legal Business Name): AMIR MOLLAEI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201
US

IV. Provider business mailing address

309 JACKSON ST
MONROE LA
71201-7407
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4000
  • Fax: 318-966-4856
Mailing address:
  • Phone: 318-966-4000
  • Fax: 318-966-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10052602
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: