Provider Demographics
NPI:1255333589
Name:CHOI, KENNETH KIEUN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KIEUN
Last Name:CHOI
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 1:6325 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3808
Mailing Address - Country:US
Mailing Address - Phone:520-795-5830
Mailing Address - Fax:520-885-4469
Practice Address - Street 1:2260 W ORANGE GROVE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3117
Practice Address - Country:US
Practice Address - Phone:520-795-5830
Practice Address - Fax:520-885-4469
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27206174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ472150Medicaid
0288760001Medicare NSC
AZ472150Medicaid