Provider Demographics
NPI:1114177664
Name:THERIOT, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:THERIOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18827 E SWAN DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5314
Mailing Address - Country:US
Mailing Address - Phone:480-275-8886
Mailing Address - Fax:
Practice Address - Street 1:4002 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8612
Practice Address - Country:US
Practice Address - Phone:480-324-5421
Practice Address - Fax:480-324-5459
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-21
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015177207L00000X
AZ44415207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ148119Medicare UPIN