Provider Demographics
NPI:1619920311
Name:MOENCH, JERRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:MOENCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5009
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5009
Mailing Address - Country:US
Mailing Address - Phone:605-977-5000
Mailing Address - Fax:605-977-5377
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:605-977-5377
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1548207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
165027OtherUCARE
SD6001200Medicaid
IA1106195Medicaid
24681OtherHEALTH PARTNERS
MN92589MOOtherMN BCBS - PLAN 91057NO
931451029038OtherPREFERRED ONE
SD0009604OtherSD BCBS
MN538R5MOOtherMN BCBS - PLAN 538R2NO
SD1548OtherDAKOTACARE
GACG5507Medicare PIN
MN92589MOOtherMN BCBS - PLAN 91057NO
24681OtherHEALTH PARTNERS