Provider Demographics
NPI:1598851750
Name:AMMON, JERRY B (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:AMMON
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 1:1215 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-5129
Mailing Address - Country:US
Mailing Address - Phone:830-379-5867
Mailing Address - Fax:830-401-4035
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001791A207L00000X
TXQ1349207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200451770Medicaid
INH94160Medicare UPIN
IN200451770Medicaid
TX364478ZHLWMedicare PIN