Provider Demographics
NPI:1538150776
Name:JURIST, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:JURIST
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 1:2720 NORTH UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-205-9824
Mailing Address - Fax:
Practice Address - Street 1:2720 NORTH UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-205-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4325207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1910708Medicaid
MI1910708Medicaid
A73353Medicare UPIN