Provider Demographics
NPI:1770640930
Name:MESA EAR NOSE AND THROAT PC
Entity Type:Organization
Organization Name:MESA EAR NOSE AND THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KETTERER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-833-8620
Mailing Address - Street 1:726 N GREENFIELD RD # 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-5012
Mailing Address - Country:US
Mailing Address - Phone:480-833-8620
Mailing Address - Fax:
Practice Address - Street 1:726 N GREENFIELD RD # 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5012
Practice Address - Country:US
Practice Address - Phone:480-833-8620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD18540207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ62384Medicare ID - Type Unspecified