Provider Demographics
NPI:1437121175
Name:PTACEK, TERRY L (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:PTACEK
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 1:1221 W LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1857
Mailing Address - Country:US
Mailing Address - Phone:850-469-3500
Mailing Address - Fax:850-469-3424
Practice Address - Street 1:1221 W LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1857
Practice Address - Country:US
Practice Address - Phone:850-469-3500
Practice Address - Fax:850-469-3424
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39221207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53338Medicare UPIN