Healthcare Provider Details

I. General information

NPI: 1174501852
Provider Name (Legal Business Name): THOMAS J KETTERER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W BROWN RD #1008
MESA AZ
85201-3221
US

IV. Provider business mailing address

560 W BROWN RD #1008
MESA AZ
85201-3221
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-8620
  • Fax:
Mailing address:
  • Phone: 480-833-8620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD18540
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: