Provider Demographics
NPI:1598783607
Name:KETTELLE, JOHN BRADFORD IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADFORD
Last Name:KETTELLE
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:SAVAHCS
Mailing Address - Street 2:3601 S. 6TH AVE.
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:520-629-4603
Practice Address - Street 1:SAVAHCS
Practice Address - Street 2:3601 S. 6TH AVE.
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:520-629-4603
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-10-21
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Provider Licenses
StateLicense IDTaxonomies
AZ36533208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ36533OtherARIZONA MEDICAL LICENSE
CAA67553OtherLICENSE
CAA67553OtherLICENSE