Basic Information
| Provider Information | |||||||||
| NPI: | 1598783607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETTELLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRADFORD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | SAVAHCS | ||||||||
| Address2: | 3601 S. 6TH AVE. | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206294603 | ||||||||
| Practice Location | |||||||||
| Address1: | SAVAHCS | ||||||||
| Address2: | 3601 S. 6TH AVE. | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206294603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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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 | 208600000X | 36533 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36533 | 01 | AZ | ARIZONA MEDICAL LICENSE | OTHER | A67553 | 01 | CA | LICENSE | OTHER |