Provider Demographics
NPI:1083895312
Name:ROMAN, TERRY MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:MARK
Last Name:ROMAN
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:SUITE 1008
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3331
Mailing Address - Country:US
Mailing Address - Phone:920-206-6500
Mailing Address - Fax:920-261-4013
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:SUITE 1008
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:920-206-6500
Practice Address - Fax:920-261-4013
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2013-08-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI54555-021207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083895312Medicaid
WI301250110Medicare PIN