Provider Demographics
NPI:1861726077
Name:KENWORTHY, DERIK K (DO)
Entity type:Individual
Prefix:
First Name:DERIK
Middle Name:K
Last Name:KENWORTHY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S CLEARVIEW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:1979 W RAY RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4007
Practice Address - Country:US
Practice Address - Phone:480-821-9404
Practice Address - Fax:480-857-1490
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO2201672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z173125OtherMEDICARE PTAN
AZ503865Medicaid