Provider Demographics
NPI:1043202856
Name:TERRELL, MERVIN DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:MERVIN
Middle Name:DALE
Last Name:TERRELL
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 1:1220 W 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7109
Mailing Address - Country:US
Mailing Address - Phone:870-541-0013
Mailing Address - Fax:870-541-0014
Practice Address - Street 1:1220 W 42ND AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7109
Practice Address - Country:US
Practice Address - Phone:870-541-0013
Practice Address - Fax:870-541-0014
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3820207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150188001Medicaid
AR5M697OtherBLUE CROSS BLUE SHIELD
AR5M690Medicare PIN
AR5M697OtherBLUE CROSS BLUE SHIELD