Healthcare Provider Details

I. General information

NPI: 1235147331
Provider Name (Legal Business Name): JERRY A MOLITOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 DELAWARE STREET SE, CLINIC 6A UMP MEDICINE SPECIALTIES CLINIC
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

720 WASHINGTON AVE SE UNIVERSITY OF MINNESOTA PHYSICIANS
MINNEAPOLIS MN
55414
US

V. Phone/Fax

Practice location:
  • Phone: 612-884-0649
  • Fax:
Mailing address:
  • Phone: 612-884-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD00035031
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: