Healthcare Provider Details

I. General information

NPI: 1437131141
Provider Name (Legal Business Name): JOHN THEROUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 S FRANKLIN ST
WILKES BARRE PA
18702-3808
US

IV. Provider business mailing address

585 CHARLES AVE
KINGSTON PA
18704-4711
US

V. Phone/Fax

Practice location:
  • Phone: 570-825-6425
  • Fax: 570-829-3337
Mailing address:
  • Phone: 570-331-2029
  • Fax: 570-829-3337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number226706
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: