Provider Demographics
NPI:1487656138
Name:GAMACHE, TERRY L (DPM)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:GAMACHE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2444
Mailing Address - Country:US
Mailing Address - Phone:636-946-9399
Mailing Address - Fax:636-947-1972
Practice Address - Street 1:1366 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2444
Practice Address - Country:US
Practice Address - Phone:636-946-9399
Practice Address - Fax:636-947-1972
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO300749900Medicaid
MOT42856Medicare UPIN
MO000021456Medicare ID - Type Unspecified