Provider Demographics
NPI:1114210085
Name:TERRY, MARISA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JEAN
Last Name:TERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 407
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5752
Mailing Address - Country:US
Mailing Address - Phone:850-916-8700
Mailing Address - Fax:
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 407
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-916-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127530208100000X
MN55801208100000X, 208100000X
MI4301098595390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018020600Medicaid
MN250001010Medicare PIN
FL018020600Medicaid