Provider Demographics
NPI:1720132962
Name:MAVERICK, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:MAVERICK
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 1:4775 HAMILTON WOLFE RD
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3463
Mailing Address - Country:US
Mailing Address - Phone:210-614-3600
Mailing Address - Fax:210-614-3604
Practice Address - Street 1:4775 HAMILTON WOLFE RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3463
Practice Address - Country:US
Practice Address - Phone:210-614-3600
Practice Address - Fax:210-614-3604
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0814207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI21914Medicare UPIN
TX8D7065Medicare ID - Type UnspecifiedINDIVIDUAL #