Provider Demographics
NPI:1114007093
Name:KILKENNY, THOMAS EUGENE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EUGENE
Last Name:KILKENNY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1165 S DORA ST
Mailing Address - Street 2:SUITE C1
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-8325
Mailing Address - Country:US
Mailing Address - Phone:707-468-0471
Mailing Address - Fax:707-468-1182
Practice Address - Street 1:1165 S DORA ST
Practice Address - Street 2:SUITE C1
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-8325
Practice Address - Country:US
Practice Address - Phone:707-468-0471
Practice Address - Fax:707-468-1182
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG33772207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G337720Medicaid
CA200008281OtherRAILROAD MEDICARE
CA00G337720Medicare ID - Type Unspecified
A45672Medicare UPIN
CA200008281OtherRAILROAD MEDICARE