Provider Demographics
NPI:1861704181
Name:MOLLA, IRIDA (MD)
Entity type:Individual
Prefix:
First Name:IRIDA
Middle Name:
Last Name:MOLLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRIDA
Other - Middle Name:
Other - Last Name:HASALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:793 EASTERN BYP
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2422
Mailing Address - Country:US
Mailing Address - Phone:859-624-6560
Mailing Address - Fax:859-624-6569
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2505
Practice Address - Country:US
Practice Address - Phone:203-574-4187
Practice Address - Fax:203-575-2153
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48240207RI0200X, 207R00000X
CT56841207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine