Healthcare Provider Details

I. General information

NPI: 1104977602
Provider Name (Legal Business Name): JERRY DANIEL AYERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 5TH AVE
SAN DIEGO CA
92101-2139
US

IV. Provider business mailing address

2121 5TH AVE STE 105
SAN DIEGO CA
92101-2139
US

V. Phone/Fax

Practice location:
  • Phone: 619-683-9394
  • Fax: 619-683-9228
Mailing address:
  • Phone: 619-683-9394
  • Fax: 619-683-9228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA42793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: