Basic Information
| Provider Information | |||||||||
| NPI: | 1467412650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENIGSBERG | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 N COUNTRY CLUB DR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852013309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804612409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 JOHNSTOWN CENTER DR | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805349030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705874974 | ||||||||
| FaxNumber: | 9705875466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37268 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01372689 | 05 | CO | MEDICAID |