Provider Demographics
NPI:1326012337
Name:MOLL, KENNETH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:MOLL
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 1:2841 DEBARR RD
Mailing Address - Street 2:STE 31
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-264-2000
Mailing Address - Fax:907-222-3298
Practice Address - Street 1:2841 DEBARR RD
Practice Address - Street 2:STE 31
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2967
Practice Address - Country:US
Practice Address - Phone:907-264-2000
Practice Address - Fax:907-222-3298
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD995DMedicaid
151964Medicare ID - Type Unspecified
C97180Medicare UPIN