Provider Demographics
NPI:1093747990
Name:MOENNING, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:MOENNING
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:PO BOX 754
Mailing Address - Street 2:
Mailing Address - City:BOCA GRANDE
Mailing Address - State:FL
Mailing Address - Zip Code:33921-0754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21450 GIBRALTER DR
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5417
Practice Address - Country:US
Practice Address - Phone:941-766-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 34134208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD 82430Medicare UPIN
FL36258YMedicare ID - Type Unspecified