Provider Demographics
NPI:1225012552
Name:MOLLICK, DARREN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:DARREN
Middle Name:KEITH
Last Name:MOLLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-921-6780
Mailing Address - Fax:
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 320
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-921-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217820-4207ND0101X
NY217820207N00000X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2K7991Medicare PIN
NYH74136Medicare UPIN