Provider Demographics
NPI:1619101326
Name:TERRY D. MOEHNKE, O.D., P.C.
Entity type:Organization
Organization Name:TERRY D. MOEHNKE, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOEHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-955-6720
Mailing Address - Street 1:25 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5021
Mailing Address - Country:US
Mailing Address - Phone:515-955-6720
Mailing Address - Fax:515-955-3555
Practice Address - Street 1:25 S 16TH ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5021
Practice Address - Country:US
Practice Address - Phone:515-955-6720
Practice Address - Fax:515-955-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1649332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0005843Medicaid
IA0005843Medicaid
IA0142870001Medicare NSC