Healthcare Provider Details

I. General information

NPI: 1386857332
Provider Name (Legal Business Name): JERRY D AYERS, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 4TH AVE
SAN DIEGO CA
92103-4202
US

IV. Provider business mailing address

3719 4TH AVE
SAN DIEGO CA
92103-4202
US

V. Phone/Fax

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

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: DR. JERRY D AYERS
Title or Position: CEO
Credential: M.D.
Phone: 619-638-9394