Provider Demographics
NPI:1336172154
Name:GERARD, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:GERARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:STE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5106
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:7915 LAKE MANASSAS DR
Practice Address - Street 2:STE 302
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3260
Practice Address - Country:US
Practice Address - Phone:571-248-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003259207L00000X
FLME96504207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56538OtherBCBSFL
FL276470900Medicaid
FLAB621ZMedicare PIN
FL276470900Medicaid