MEDICARE: DR. CALLIE J MOLLOY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6517T	TX
2	152W00000X	Optometrist	2152	CO
3	152W00000X	Optometrist	2802T	OR

General Provider Information

NPI Number	:	1205814365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CALLIE J MOLLOY O.D.

Provider Business Mailing Address
First Line	:	327 CASTANO AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3749
Country	:	US
Telephone Number	:	210-824-6519
Fax Number	:

Provider Business Practice Location Address
First Line	:	1430 AUSTIN HWY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-4338
Country	:	US
Telephone Number	:	210-650-3823
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2006
Last Update Date	:	07/08/2007

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