Provider Demographics
NPI:1992788673
Name:MOLEDOR, JEFFERY J (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:J
Last Name:MOLEDOR
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 1:1930 CROWN PARK CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-2402
Mailing Address - Country:US
Mailing Address - Phone:614-457-1793
Mailing Address - Fax:614-457-4051
Practice Address - Street 1:1930 CROWN PARK CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-2402
Practice Address - Country:US
Practice Address - Phone:614-457-1793
Practice Address - Fax:614-457-4051
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-6701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0719128Medicaid
OH0719128Medicaid
OHA82874Medicare UPIN