Provider Demographics
NPI:1669449229
Name:MAYER, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:MAYER
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 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:3101 UNIVERSITY BLVD S STE 102
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2750
Practice Address - Country:US
Practice Address - Phone:904-737-1171
Practice Address - Fax:904-739-8022
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600428207Q00000X
FLME102168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1951AOtherBPC GROUP PTAN
FLP00657003OtherMEDICARE RR
FLP00657003OtherMEDICARE RR
FLK1951AOtherBPC GROUP PTAN
FLP00657003OtherMEDICARE RR
NC1426VOtherBCBS OF NC
FLK1951AOtherBPC GROUP PTAN
NC5905591Medicaid
FLAM149ZMedicare PIN