1679008510 NPI number — JACK KENNINGTON AYRES MD

Table of content: JACK KENNINGTON AYRES MD (NPI 1679008510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679008510 NPI number — JACK KENNINGTON AYRES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AYRES
Provider First Name:
JACK
Provider Middle Name:
KENNINGTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679008510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3551 ROGER BROOKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SAM HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78234-4504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
549 HC/BAACH
Provider Second Line Business Practice Location Address:
UNIT 15245
Provider Business Practice Location Address City Name:
DAEGU
Provider Business Practice Location Address State Name:
GYIONGSANGNAM
Provider Business Practice Location Address Postal Code:
96271
Provider Business Practice Location Address Country Code:
KR
Provider Business Practice Location Address Telephone Number:
315-764-5595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  0101266126 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0101266126 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com