Provider Demographics
NPI:1154339547
Name:MOISE, KENNETH JOSEPH JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:MOISE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 MUELLER BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723
Mailing Address - Country:US
Mailing Address - Phone:512-324-7256
Mailing Address - Fax:
Practice Address - Street 1:4910 MUELLER BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723
Practice Address - Country:US
Practice Address - Phone:512-324-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9624207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133880817Medicaid
TX8L2196Medicare PIN
TXTXB117227Medicare PIN
D74296Medicare UPIN
TX8G8544Medicare PIN
TX8G8660Medicare PIN