Provider Demographics
NPI:1477539724
Name:TER POORTEN, MARYANNA C (MD)
Entity Type:Individual
Prefix:
First Name:MARYANNA
Middle Name:C
Last Name:TER POORTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1221
Mailing Address - Country:US
Mailing Address - Phone:704-784-5901
Mailing Address - Fax:704-721-0413
Practice Address - Street 1:335 PENNY LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1221
Practice Address - Country:US
Practice Address - Phone:704-784-5901
Practice Address - Fax:704-721-0413
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-00893207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134VKMedicaid
NCP00232695OtherMEDICARE RAILROAD
NC1434Medicare PIN
NCH88863Medicare UPIN