Provider Demographics
NPI:1376548800
Name:PETERSON-HENRY, TERRI A (DO)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:PETERSON-HENRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-4540
Mailing Address - Fax:605-328-4531
Practice Address - Street 1:7220 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6038
Practice Address - Country:US
Practice Address - Phone:605-328-9600
Practice Address - Fax:605-328-9620
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3555207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5609168Medicaid
SD080193498Medicare PIN
SDF36426Medicare UPIN
SD080193519Medicare PIN
SD5609168Medicaid