Provider Demographics
NPI:1033120282
Name:MOGHADAM, KENNETH K (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:K
Last Name:MOGHADAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11725 N ILLINOIS ST
Mailing Address - Street 2:SUITE 515
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3008
Mailing Address - Country:US
Mailing Address - Phone:317-814-4110
Mailing Address - Fax:317-814-4114
Practice Address - Street 1:11725 N ILLINOIS ST
Practice Address - Street 2:SUITE 515
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3008
Practice Address - Country:US
Practice Address - Phone:317-814-4110
Practice Address - Fax:317-814-4114
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01051029A207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000366889OtherANTHEM
IN000000366889OtherANTHEM