Provider Demographics
NPI:1114025665
Name:NULL, TERRY N (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:N
Last Name:NULL
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 1:9650 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46229
Mailing Address - Country:US
Mailing Address - Phone:317-890-5548
Mailing Address - Fax:317-890-5620
Practice Address - Street 1:9650 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46229
Practice Address - Country:US
Practice Address - Phone:317-890-5548
Practice Address - Fax:317-890-5620
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T93584Medicare UPIN
IN1205720003Medicare NSC
IN675840DMedicare ID - Type Unspecified