Provider Demographics
NPI:1093719080
Name:ELLINGTON, TERRY W (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:W
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:116 CROWFOOT CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-6765
Mailing Address - Country:US
Mailing Address - Phone:336-775-1734
Mailing Address - Fax:336-775-1734
Practice Address - Street 1:2910 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3016
Practice Address - Country:US
Practice Address - Phone:336-724-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909668Medicaid
NC2469243GMedicare ID - Type Unspecified
NC8909668Medicaid