Provider Demographics
NPI:1083649735
Name:MOE, KYAW (MD)
Entity Type:Individual
Prefix:DR
First Name:KYAW
Middle Name:
Last Name:MOE
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 1:3650 SOUTH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1502
Mailing Address - Country:US
Mailing Address - Phone:562-286-6466
Mailing Address - Fax:562-286-6465
Practice Address - Street 1:3650 SOUTH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1502
Practice Address - Country:US
Practice Address - Phone:562-286-6466
Practice Address - Fax:562-286-6465
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429546207R00000X
CAA109324207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101707491Medicaid
PA232359401OtherMAIN LINE HEALTHCARE
PA101707491Medicaid
CAW16145AMedicare Oscar/Certification