Provider Demographics
NPI:1538691746
Name:TERRY, KRISTIN JOAN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JOAN
Last Name:TERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JOAN
Other - Last Name:HERTWECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-821-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137522207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111643200Medicaid
FLLGJQ5OtherBLUE CROSS BLUE SHIELD