Provider Demographics
NPI:1275517492
Name:TER RIET, MENNO F (MD)
Entity Type:Individual
Prefix:
First Name:MENNO
Middle Name:F
Last Name:TER RIET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:851 TRAFALGAR CT.
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:904-398-5397
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME71589207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259369600Medicaid
FL35467YMedicare ID - Type Unspecified
FLW10562Medicare UPIN