Provider Demographics
NPI:1437131141
Name:THEROUX, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:THEROUX
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 1:585 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4711
Mailing Address - Country:US
Mailing Address - Phone:570-331-2029
Mailing Address - Fax:570-829-3337
Practice Address - Street 1:335 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3808
Practice Address - Country:US
Practice Address - Phone:570-825-6425
Practice Address - Fax:570-829-3337
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2267062084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33025FMedicare ID - Type Unspecified