Provider Demographics
NPI:1457349417
Name:THEK, KERRY DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:DIANE
Last Name:THEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1690 DUNLAWTON AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8980
Mailing Address - Country:US
Mailing Address - Phone:386-271-2273
Mailing Address - Fax:386-271-2274
Practice Address - Street 1:1690 DUNLAWTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8980
Practice Address - Country:US
Practice Address - Phone:386-677-0531
Practice Address - Fax:386-673-4658
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-112122080P0206X
FLME583962080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064841800Medicaid
FL11707WMedicare PIN