Provider Demographics
NPI:1467412650
Name:KENIGSBERG, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:KENIGSBERG
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 1:1010 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3309
Mailing Address - Country:US
Mailing Address - Phone:480-461-2409
Mailing Address - Fax:
Practice Address - Street 1:222 JOHNSTOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9030
Practice Address - Country:US
Practice Address - Phone:970-587-4974
Practice Address - Fax:970-587-5466
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01372689Medicaid
C227348Medicare PIN
CO01372689Medicaid
C173538Medicare PIN
G75903Medicare UPIN