Healthcare Provider Details

I. General information

NPI: 1902122781
Provider Name (Legal Business Name): KENNETH K TIEU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 N WICKHAM RD
MELBOURNE FL
32940-2239
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-9230
  • Fax: 321-434-9269
Mailing address:
  • Phone: 321-434-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME114362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: