Provider Demographics
NPI:1861585887
Name:MOLL, ERIC MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MARTIN
Last Name:MOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 PENINSULA ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3954
Mailing Address - Country:US
Mailing Address - Phone:805-652-5018
Mailing Address - Fax:805-650-0474
Practice Address - Street 1:147 N BRENT SREET
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-652-5011
Practice Address - Fax:805-585-3007
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68497146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ53994ZOtherBLUE SHIELD
CAZZT40394FMedicaid
CAG68497OtherLICENSE NUMBER
CAHSC30394FMedicaid
CA050394OtherBLUE CROSS
CAZZZA56032OtherBLUE SHIELD
CAZZT40394FMedicaid
CAE60046Medicare UPIN