Provider Demographics
NPI:1205860392
Name:FORD, KERRY K (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:K
Last Name:FORD
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 2987
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78627-2987
Mailing Address - Country:US
Mailing Address - Phone:512-948-7093
Mailing Address - Fax:
Practice Address - Street 1:510 E 15TH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-6941
Practice Address - Country:US
Practice Address - Phone:512-948-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE60802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132150703Medicaid
TX84R121Medicare ID - Type Unspecified
C15657Medicare UPIN