Individual
DR. KERRY DIANE THEK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1690 DUNLAWTON AVE STE 120, PORT ORANGE, FL 32127-8980
(386) 677-0531
(386) 673-4658
Mailing address
1690 DUNLAWTON AVE STE 120, PORT ORANGE, FL 32127-8980
(386) 271-2273
(386) 271-2274
Taxonomy
Speciality
Code
Description
License number
State
2080P0206X
Pediatric Gastroenterology Physician
E-11212
AR
2080P0206X
Pediatric Gastroenterology Physician
Primary
ME58396
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
064841800
—
FL
Enumeration date
10/12/2005
Last updated
05/23/2018
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