Healthcare Provider Details

I. General information

NPI: 1427430396
Provider Name (Legal Business Name): TRACY J MOLL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 HEALTH CAMPUS DR
ROCKINGHAM VA
22801-8679
US

IV. Provider business mailing address

2006 HEALTH CAMPUS DR
ROCKINGHAM VA
22801-8679
US

V. Phone/Fax

Practice location:
  • Phone: 540-689-5400
  • Fax: 757-579-8568
Mailing address:
  • Phone: 540-689-5400
  • Fax: 757-579-8568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2015020142
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0102205567
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: