1033120282 NPI number — DR. KENNETH K MOGHADAM M.D.

Table of content: DR. KENNETH K MOGHADAM M.D. (NPI 1033120282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033120282 NPI number — DR. KENNETH K MOGHADAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOGHADAM
Provider First Name:
KENNETH
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033120282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11725 N ILLINOIS ST
Provider Second Line Business Mailing Address:
SUITE 515
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-3008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-814-4110
Provider Business Mailing Address Fax Number:
317-814-4114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 N ILLINOIS ST
Provider Second Line Business Practice Location Address:
SUITE 515
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-3008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-814-4110
Provider Business Practice Location Address Fax Number:
317-814-4114
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  01051029A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000366889 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com