Provider Demographics
NPI:1902131774
Name:MOLEN, BRYAN HANEY (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:HANEY
Last Name:MOLEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 BROAD PARK CIR S STE 205
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7834
Mailing Address - Country:US
Mailing Address - Phone:682-223-2400
Mailing Address - Fax:682-207-6612
Practice Address - Street 1:305 REGENCY PKWY STE 801
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3794
Practice Address - Country:US
Practice Address - Phone:682-223-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002340213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB152313Medicare PIN