Provider Demographics
NPI:1659303642
Name:KERNER, THEODORE CHARLES JR (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:CHARLES
Last Name:KERNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3010 TRENWEST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3208
Mailing Address - Country:US
Mailing Address - Phone:336-970-5000
Mailing Address - Fax:336-970-5298
Practice Address - Street 1:3155 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-794-4372
Practice Address - Fax:336-659-2379
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC384822085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948556Medicaid
NC2147448KMedicare PIN
E15089Medicare UPIN
NC2147448JMedicare PIN
NC2147448PMedicare PIN
NC2147448AMedicare PIN
NC2147448MMedicare PIN
NC2147448NMedicare PIN