1548780133 NPI number — DR. MOLLY JOAN KING -GOVE OD

Table of content: DR. MOLLY JOAN KING -GOVE OD (NPI 1548780133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548780133 NPI number — DR. MOLLY JOAN KING -GOVE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING -GOVE
Provider First Name:
MOLLY
Provider Middle Name:
JOAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548780133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 ROCKINGHAM AVE APT 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ROXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02132-4523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-268-6480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
468 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST JOHNSBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05819-9225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-223-7723
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  030.0133932 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 5241 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)