Provider Demographics
NPI:1275543845
Name:MOSES, KENNETH P (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:MOSES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2107 LIVINGSTON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-5218
Mailing Address - Country:US
Mailing Address - Phone:510-436-9000
Mailing Address - Fax:510-436-9013
Practice Address - Street 1:2107 LIVINGSTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-5218
Practice Address - Country:US
Practice Address - Phone:510-436-9000
Practice Address - Fax:510-436-9013
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA70905207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A709050Medicaid
CA00A709053Medicare PIN