Healthcare Provider Details

I. General information

NPI: 1356616692
Provider Name (Legal Business Name): HARRY JOSEPH MOLLIGAN IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 204
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

600 GRESHAM DR STE 204
NORFOLK VA
23507-1904
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-5680
  • Fax: 757-388-5681
Mailing address:
  • Phone: 757-388-5680
  • Fax: 757-388-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2018-01130
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME130036
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101264068
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: