Basic Information
Provider Information | |||||||||
NPI: | 1073522652 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KETZ | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BOX 665 | ||||||||
Address2: | 601 ELMWOOD AVE | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 14642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5852733126 | ||||||||
FaxNumber: | 5857564721 | ||||||||
Practice Location | |||||||||
Address1: | 601 ELMWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 14642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5852733126 | ||||||||
FaxNumber: | 5852733126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 09/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME 97677 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0004X | ME 97677 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0801X | 258179 | NY | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
ID | Type | State | Issuer | Description | 27844830-0 | 05 | FL |   | MEDICAID | 96123 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER | 1073522652 | 05 | VA |   | MEDICAID | 310407 | 01 | FL | AVMED | OTHER | 5918946 | 01 | FL | CIGNA | OTHER |