Provider Demographics
NPI:1154488831
Name:FONVILLE, TERRY WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:WAYNE
Last Name:FONVILLE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:99 UNIVERSITY PL
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4575
Mailing Address - Country:US
Mailing Address - Phone:212-222-7516
Mailing Address - Fax:212-529-6222
Practice Address - Street 1:99 UNIVERSITY PL
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4528
Practice Address - Country:US
Practice Address - Phone:212-222-7516
Practice Address - Fax:212-529-6222
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-07-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY107804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB19473Medicare UPIN
NY82A741Medicare ID - Type Unspecified