Provider Demographics
NPI:1417933755
Name:WITHAM, TERENCE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:TERENCE
Middle Name:LEIGH
Last Name:WITHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 NORTHCLIFF AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3267
Mailing Address - Country:US
Mailing Address - Phone:216-661-4577
Mailing Address - Fax:216-661-4784
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:216-661-4577
Practice Address - Fax:216-661-4784
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0815872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256582Medicaid
OH2350147Medicaid
OH000000241215OtherANTHEM PIN
OH260051953OtherRAILROAD MEDICARE PIN
OH2350147Medicaid
OH4093382Medicare PIN
OHH71394Medicare UPIN
OH4093381Medicare PIN
OH9932026Medicare PIN