Healthcare Provider Details

I. General information

NPI: 1033120282
Provider Name (Legal Business Name): KENNETH K MOGHADAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 N ILLINOIS ST SUITE 515
CARMEL IN
46032-3008
US

IV. Provider business mailing address

11725 N ILLINOIS ST SUITE 515
CARMEL IN
46032-3008
US

V. Phone/Fax

Practice location:
  • Phone: 317-814-4110
  • Fax: 317-814-4114
Mailing address:
  • Phone: 317-814-4110
  • Fax: 317-814-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number01051029A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: