Provider Demographics
NPI:1407859994
Name:SHIPE, TERRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:SHIPE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 E MAUMEE ST STE 201
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2035
Practice Address - Country:US
Practice Address - Phone:260-665-7595
Practice Address - Fax:260-665-6586
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2022-11-15
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IN01029019A207Q00000X
IN207000000X207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100329370AMedicaid
IN100329370AMedicaid
INC25611Medicare UPIN