Provider Demographics
NPI:1033280540
Name:TERRY, ROBERT BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:TERRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1385
Mailing Address - Country:US
Mailing Address - Phone:740-446-1760
Mailing Address - Fax:740-446-1550
Practice Address - Street 1:1371 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1385
Practice Address - Country:US
Practice Address - Phone:740-446-1760
Practice Address - Fax:740-446-1550
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTE0511491Medicare PIN
OHT47537Medicare UPIN