Provider Demographics
NPI:1932109360
Name:KETNER, GERALD MAX (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MAX
Last Name:KETNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N LOOP 340
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2486
Mailing Address - Country:US
Mailing Address - Phone:254-799-8343
Mailing Address - Fax:254-799-1922
Practice Address - Street 1:1139 N LOOP 340
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2486
Practice Address - Country:US
Practice Address - Phone:254-799-8343
Practice Address - Fax:254-799-1922
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4680111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0019846-01Medicaid
TXU14212Medicare UPIN
TX0019846-01Medicaid