Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | 02033 | IA |
NPI | 1447226840 |
---|---|
Provider Name | Kenneth H Moon Jr |
First Address | Des Moines, IA 50316-1901 |
Second Address | Des Moines, IA 50316-1901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2006 |
Last Update Date | 09/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1447226840 | (05) | IA |
2215236 | (05) | IA |
D46556 | (02) | IA |