Provider Demographics
NPI:1073522652
Name:KETZ, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:KETZ
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:BOX 665
Mailing Address - Street 2:601 ELMWOOD AVE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642
Mailing Address - Country:US
Mailing Address - Phone:585-273-3126
Mailing Address - Fax:585-756-4721
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-273-3126
Practice Address - Fax:585-273-3126
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 97677207X00000X, 207XX0004X
NY258179207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073522652Medicaid
FL96123OtherBLUE CROSS/BLUE SHIELD
FL310407OtherAVMED
FL27844830-0Medicaid
FL5918946OtherCIGNA
VA1073522652Medicaid
VAMC10475Medicare PIN