Provider Demographics
NPI:1104587997
Name:MOLS, MATTHEW JACOB
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:MOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 SURREY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2397
Mailing Address - Country:US
Mailing Address - Phone:815-501-2609
Mailing Address - Fax:
Practice Address - Street 1:503 SURREY WOODS DR
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2397
Practice Address - Country:US
Practice Address - Phone:815-501-2609
Practice Address - Fax:630-549-6967
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care