Provider Demographics
NPI:1679008510
Name:AYRES, JACK KENNINGTON (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:KENNINGTON
Last Name:AYRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:549 HC/BAACH
Practice Address - Street 2:UNIT 15245
Practice Address - City:DAEGU
Practice Address - State:GYIONGSANGNAM
Practice Address - Zip Code:96271
Practice Address - Country:KR
Practice Address - Phone:315-764-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266126208D00000X
286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101266126Medicaid