Healthcare Provider Details

I. General information

NPI: 1598589780
Provider Name (Legal Business Name): MOLLIE CAMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

1726 FREMONT AVE
MADISON WI
53704-3914
US

V. Phone/Fax

Practice location:
  • Phone: 608-228-3597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number83799-875
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: