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NPI Code Detail

MEDICARE: DR. DEREK ALLEN MOLINE O.D.

MEDICARE: DR. DEREK ALLEN MOLINE 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
1152W00000XOptometrist2783MN

General Provider Information

NPI Number : 1588630925
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DEREK ALLEN MOLINE O.D.
Provider Business Mailing Address
First Line : 8170 33RD AVE S
Second Line : MS 21110Q
City : BLOOMINGTON
State : MN
Zip : 55425-4516
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1210 COUNTY RD E
Second Line :
City : ARDEN HILLS
State : MN
Zip : 55112-3783
Country : US
Telephone Number : 651-523-8400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/26/2006
Last Update Date : 03/07/2024

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