Provider Demographics
NPI:1639164189
Name:MOY, KENNETH CHI-KONG (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CHI-KONG
Last Name:MOY
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 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-7696
Mailing Address - Fax:
Practice Address - Street 1:201 PLAZA DR STE C
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5105
Practice Address - Country:US
Practice Address - Phone:573-481-2210
Practice Address - Fax:573-481-2220
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105230207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247653116Medicaid
MOF87268Medicare UPIN
MO000094615Medicare ID - Type Unspecified