Provider Demographics
NPI:1184656332
Name:COBB, TERRY LAMAR
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LAMAR
Last Name:COBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-5809
Mailing Address - Country:US
Mailing Address - Phone:229-985-2273
Mailing Address - Fax:229-985-2270
Practice Address - Street 1:1321 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5809
Practice Address - Country:US
Practice Address - Phone:229-985-2273
Practice Address - Fax:229-985-2270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20017139030171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52704189001OtherBLUE CROSS BLUE SHIELD
GA5526230001Medicare NSC