Healthcare Provider Details

I. General information

NPI: 1720121684
Provider Name (Legal Business Name): ALLEN R MOLLOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NW 64TH ST
OKLAHOMA CITY OK
73116-9107
US

IV. Provider business mailing address

PO BOX 411804
BOSTON MA
02241-1804
US

V. Phone/Fax

Practice location:
  • Phone: 572-218-9900
  • Fax:
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036163488
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number22334
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number22334
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: