Provider Demographics
NPI:1164423307
Name:TERRELL, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TERRELL
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 1:4410 MEDICAL DR
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6306
Mailing Address - Country:US
Mailing Address - Phone:210-692-9400
Mailing Address - Fax:210-692-9601
Practice Address - Street 1:4410 MEDICAL DR
Practice Address - Street 2:SUITE 440
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6306
Practice Address - Country:US
Practice Address - Phone:210-692-9400
Practice Address - Fax:210-692-9601
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6649207RP1001X, 207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133977208Medicaid
TX8U5580OtherBLUE CROSS BLUE SHIELD
TXB26930Medicare UPIN
TXF-2038Medicare PIN