Healthcare Provider Details

I. General information

NPI: 1730529660
Provider Name (Legal Business Name): IAN WENTWORTH MOLYNEAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 202-631-7127
  • Fax:
Mailing address:
  • Phone: 202-631-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number59016
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number59016
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: