Provider Demographics
NPI:1891769360
Name:ROOT, KEN ERNEST JR (DO)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:ERNEST
Last Name:ROOT
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:2730 S VAL VISTA DR
Mailing Address - Street 2:SUITE # 146
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1675
Mailing Address - Country:US
Mailing Address - Phone:480-926-0644
Mailing Address - Fax:480-926-0645
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:SUITE # 146
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1675
Practice Address - Country:US
Practice Address - Phone:480-926-0644
Practice Address - Fax:480-926-0645
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2007-09-04
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Provider Licenses
StateLicense IDTaxonomies
AZ16882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE20698Medicare UPIN