Basic Information
| Provider Information | |||||||||
| NPI: | 1891769360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROOT | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | ERNEST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 S VAL VISTA DR | ||||||||
| Address2: | SUITE # 146 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809260644 | ||||||||
| FaxNumber: | 4809260645 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 S VAL VISTA DR | ||||||||
| Address2: | SUITE # 146 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809260644 | ||||||||
| FaxNumber: | 4809260645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 1688 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.