Provider Demographics
NPI:1174501852
Name:KETTERER, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KETTERER
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 1:560 W BROWN RD
Mailing Address - Street 2:#1008
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3221
Mailing Address - Country:US
Mailing Address - Phone:480-833-8620
Mailing Address - Fax:
Practice Address - Street 1:560 W BROWN RD
Practice Address - Street 2:#1008
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3221
Practice Address - Country:US
Practice Address - Phone:480-833-8620
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD18540207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE04143Medicare UPIN
AZ62386Medicare ID - Type UnspecifiedGROUP ID 62384