Provider Demographics
NPI:1033137112
Name:TERRELL, ROBERT EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:TERRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-3424
Practice Address - Street 1:3635 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5711
Practice Address - Country:US
Practice Address - Phone:228-875-1849
Practice Address - Fax:228-875-6257
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15129207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117983Medicaid
D42875Medicare UPIN
MS00117983Medicaid