Provider Demographics
NPI:1508949157
Name:TERRY, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:TERRY
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:PO BOX 241279
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-5279
Mailing Address - Country:US
Mailing Address - Phone:402-397-1531
Mailing Address - Fax:402-397-0456
Practice Address - Street 1:1600 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:ONAWA
Practice Address - State:IA
Practice Address - Zip Code:51040-1548
Practice Address - Country:US
Practice Address - Phone:712-423-2311
Practice Address - Fax:712-423-9362
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA225642085R0202X
NE150712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7914150Medicaid
IAI7046Medicare ID - Type UnspecifiedIOWA MEDICARE
IA7914150Medicaid
IAD89672Medicare UPIN