Provider Demographics
NPI:1033278809
Name:MOSES, KENNETT J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETT
Middle Name:J
Last Name:MOSES
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 1:1145 STURGIS ROAD
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278
Mailing Address - Country:US
Mailing Address - Phone:760-830-2117
Mailing Address - Fax:
Practice Address - Street 1:1145 STURGIS ROAD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8275
Practice Address - Country:US
Practice Address - Phone:608-302-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052596A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01052596AOtherPHYSICIAN