Provider Demographics
NPI:1235453093
Name:TERRY, JUSTIN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:W
Last Name:TERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HORIZON RIDGE PKWY #150
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052
Mailing Address - Country:US
Mailing Address - Phone:702-990-0622
Mailing Address - Fax:750-938-1473
Practice Address - Street 1:2450 W HORIZON RIDGE PKWY #150
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052
Practice Address - Country:US
Practice Address - Phone:702-990-0622
Practice Address - Fax:750-938-1473
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14755207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12540672OtherCAQH
1235453093OtherNPI
NV14755OtherMEDICAL LICENSE