Individual
KENNETH H MOON JR
Active
Individual
KENNETH H MOON JR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Taxonomy
Speciality
Code
Description
License number
State
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
02033
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1447226840
—
IA
05
—
2215236
—
IA
Enumeration date
02/24/2006
Last updated
08/09/2012
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