Provider Demographics
NPI:1679567481
Name:MOEHNKE, TERRY DONN (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:DONN
Last Name:MOEHNKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5021
Mailing Address - Country:US
Mailing Address - Phone:515-955-6720
Mailing Address - Fax:515-955-3555
Practice Address - Street 1:25 S 16TH ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5021
Practice Address - Country:US
Practice Address - Phone:515-955-6720
Practice Address - Fax:515-955-3555
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1649152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0005843Medicaid
IA07718Medicare ID - Type Unspecified
IA0142870001Medicare NSC
IA0005843Medicaid