Provider Demographics
NPI:1447226840
Name:MOON JR, KENNETH H (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:MOON JR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-1901
Mailing Address - Country:US
Mailing Address - Phone:515-262-0404
Mailing Address - Fax:515-262-0489
Practice Address - Street 1:2301 EAST 14TH STREET
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-1901
Practice Address - Country:US
Practice Address - Phone:515-262-0404
Practice Address - Fax:515-262-0489
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02033207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1447226840Medicaid
IA2215236Medicaid
IA2215236Medicaid
IA719260388Medicare PIN
IAD46556Medicare UPIN