Provider Demographics
NPI:1285608752
Name:MOOK, KENNETH ALLAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLAN
Last Name:MOOK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2614 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-3828
Practice Address - Country:US
Practice Address - Phone:504-291-5100
Practice Address - Fax:504-291-5125
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88900208100000X
KY31321208100000X
LA335350208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1102772OtherPASSPORT
KY61-1086535OtherTAX ID
IN200179480Medicaid
KY64-313216Medicaid
KY64313216Medicaid
KY000000074661OtherANTHEM PROVIDER #
KY2436318000OtherPASSPORT ADVANTAGE
KY1102772OtherPASSPORT
KY61-1086535OtherTAX ID
IN200179480Medicaid
KY64313216Medicaid