Healthcare Provider Details

I. General information

NPI: 1245678838
Provider Name (Legal Business Name): TEDDY GONZALES AJERO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US NMRTC SIGONELLA PSC 836 BOX 2670
DPO AE
09636-0004
US

IV. Provider business mailing address

PSC 836 BOX 214
FPO AE
09636-0004
US

V. Phone/Fax

Practice location:
  • Phone: 314-624-2821
  • Fax:
Mailing address:
  • Phone: 314-624-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberA132084
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA132084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: