Provider Demographics
NPI:1083697593
Name:RHODES, KERRY (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:RHODES
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:PO BOX 52001
Mailing Address - Street 2:DEPT 936
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2001
Mailing Address - Country:US
Mailing Address - Phone:512-459-3177
Mailing Address - Fax:512-459-9341
Practice Address - Street 1:631 W 38TH ST
Practice Address - Street 2:#2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1250
Practice Address - Country:US
Practice Address - Phone:512-459-3177
Practice Address - Fax:512-459-9341
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0088AROtherBCBS
122412100OtherFIRST CARE
0088AROtherBCBS
122412100OtherFIRST CARE