Provider Demographics
NPI:1497714554
Name:CHRISTOPHERSON, TERRY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LYNN
Last Name:CHRISTOPHERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-0076
Mailing Address - Country:US
Mailing Address - Phone:715-268-2004
Mailing Address - Fax:715-268-5432
Practice Address - Street 1:341 KELLER AVE N
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1037
Practice Address - Country:US
Practice Address - Phone:715-268-2004
Practice Address - Fax:715-268-5432
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1530035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38564500Medicaid
MN92262CHOtherBCBS MN COM INS CO
WI0655030001Medicare NSC
MN92262CHOtherBCBS MN COM INS CO
WI38564500Medicaid