Provider Demographics
NPI:1396716379
Name:MOLES, KEN LEE (MD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:LEE
Last Name:MOLES
Suffix:
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 1:9409 B OLD BURKE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015
Mailing Address - Country:US
Mailing Address - Phone:703-978-4200
Mailing Address - Fax:703-503-8263
Practice Address - Street 1:9409 B OLD BURKE LAKE RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015
Practice Address - Country:US
Practice Address - Phone:703-978-4200
Practice Address - Fax:703-503-8263
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5638216Medicaid
003103B05Medicare ID - Type Unspecified
VA5638216Medicaid
F15655Medicare UPIN