Provider Demographics
NPI:1538182712
Name:AVERILL, KENNETH EARL JR (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EARL
Last Name:AVERILL
Suffix:JR
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1685B COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1703
Practice Address - Country:US
Practice Address - Phone:831-476-7711
Practice Address - Fax:831-475-5097
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG680882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA009680880Medicaid
00G680882Medicare PIN
300034679Medicare PIN
A31502Medicare UPIN
00G680881Medicare PIN
00G680883Medicare PIN