Provider Demographics
NPI:1528165669
Name:MOLENAAR, GORDON WESLEY (OD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:WESLEY
Last Name:MOLENAAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3546 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438
Mailing Address - Country:US
Mailing Address - Phone:708-474-0078
Mailing Address - Fax:708-474-0141
Practice Address - Street 1:3546 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438
Practice Address - Country:US
Practice Address - Phone:708-474-0078
Practice Address - Fax:708-474-0141
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL466097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00224420001OtherDMERC
1684016OtherBLUE CROSS BLUE SHIELD IL
1684016OtherBLUE CROSS BLUE SHIELD IL
T36604Medicare UPIN