MEDICARE: TERRY D. MOEHNKE, O.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	1649	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619101326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRY D. MOEHNKE, O.D., P.C.

Provider Business Mailing Address
First Line	:	25 S 16TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-5021
Country	:	US
Telephone Number	:	515-955-6720
Fax Number	:	515-955-3555

Provider Business Practice Location Address
First Line	:	25 S 16TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-5021
Country	:	US
Telephone Number	:	515-955-6720
Fax Number	:	515-955-3555

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TERRY D. MOEHNKE
Credential	:	O.D.
Telephone Number	:	515-955-6720

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	09/24/2010

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