Provider Demographics
NPI:1326106956
Name:KUETTEL, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:KUETTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:NY
Mailing Address - Zip Code:12197-0637
Mailing Address - Country:US
Mailing Address - Phone:607-397-4052
Mailing Address - Fax:607-397-4052
Practice Address - Street 1:9556 STATE HIGHWAY 7, UNIT 2
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:NY
Practice Address - Zip Code:12197-1219
Practice Address - Country:US
Practice Address - Phone:518-281-7987
Practice Address - Fax:607-397-4052
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166689207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01246217Medicaid
NY01246217Medicaid
J400058422Medicare PIN