Provider Demographics
NPI:1477138451
Name:MARTIN, TERRY J
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5108
Mailing Address - Country:US
Mailing Address - Phone:405-425-0437
Mailing Address - Fax:
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5108
Practice Address - Country:US
Practice Address - Phone:405-425-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172V00000X
172V00000X, 261QC1500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health