Provider Demographics
NPI:1063607646
Name:KY, MOL (DO)
Entity type:Individual
Prefix:
First Name:MOL
Middle Name:
Last Name:KY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:333 REVOLUTIONARY TRAIL
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827
Mailing Address - Country:US
Mailing Address - Phone:803-632-2533
Mailing Address - Fax:803-632-2451
Practice Address - Street 1:333 REVOLUTIONARY TRAIL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827
Practice Address - Country:US
Practice Address - Phone:803-632-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD01101TL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice