Provider Demographics
NPI:1245678838
Name:AJERO, TEDDY GONZALES JR (MD)
Entity type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:GONZALES
Last Name:AJERO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PSC 836 BOX 214
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09636-0004
Mailing Address - Country:US
Mailing Address - Phone:314-624-2821
Mailing Address - Fax:
Practice Address - Street 1:US NMRTC SIGONELLA
Practice Address - Street 2:PSC 836 BOX 2670
Practice Address - City:DPO
Practice Address - State:AE
Practice Address - Zip Code:09636-0004
Practice Address - Country:US
Practice Address - Phone:314-624-2821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132084171000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider