Provider Demographics
NPI:1245225317
Name:TERHAAR, KENNETH ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALBERT
Last Name:TERHAAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214
Mailing Address - Country:US
Mailing Address - Phone:904-542-7363
Mailing Address - Fax:
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01012332112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology