Provider Demographics
NPI:1174707087
Name:MOLL, LEE ANN (OD)
Entity type:Individual
Prefix:DR
First Name:LEE ANN
Middle Name:
Last Name:MOLL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:ANN
Other - Last Name:MOLL-LEAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4102 JACKSBORO HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2747
Mailing Address - Country:US
Mailing Address - Phone:940-696-9072
Mailing Address - Fax:940-761-1115
Practice Address - Street 1:4102 JACKSBORO HWY STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2747
Practice Address - Country:US
Practice Address - Phone:940-696-9072
Practice Address - Fax:940-761-1115
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3892T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0247Medicare UPIN