Provider Demographics
NPI:1902122781
Name:TIEU, KENNETH K (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:K
Last Name:TIEU
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9230
Mailing Address - Fax:
Practice Address - Street 1:8725 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2239
Practice Address - Country:US
Practice Address - Phone:321-434-9230
Practice Address - Fax:321-434-9269
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114362208600000X, 208G00000X, 208600000X
TXN6718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGQ944YOtherFL MEDICARE
FL117762000Medicaid