Provider Demographics
NPI:1689855868
Name:WARAM, KETHES C (MD)
Entity Type:Individual
Prefix:
First Name:KETHES
Middle Name:C
Last Name:WARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KETHESWARAM
Other - Middle Name:
Other - Last Name:CARUPPANNAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 98819
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8819
Mailing Address - Country:US
Mailing Address - Phone:602-867-8644
Mailing Address - Fax:602-795-5698
Practice Address - Street 1:3805 E BELL RD
Practice Address - Street 2:SUITE 3100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2105
Practice Address - Country:US
Practice Address - Phone:602-867-8644
Practice Address - Fax:602-795-5698
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44779207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ707554Medicaid
AZ707554Medicaid