Provider Demographics
NPI:1588752836
Name:LIECHTY, KENNETH W (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:LIECHTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:535 N WILMOT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2683
Mailing Address - Country:US
Mailing Address - Phone:520-694-5437
Mailing Address - Fax:520-874-7070
Practice Address - Street 1:535 N WILMOT RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2683
Practice Address - Country:US
Practice Address - Phone:520-694-5437
Practice Address - Fax:520-874-7070
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0598906208600000X
CODR.00540692086S0120X
MS208172086S0120X
AZ664942086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09329830Medicaid
PA001743468Medicaid
PA069002J5PMedicare ID - Type Unspecified
PA001743468Medicaid
MS302I025538Medicare PIN