Provider Demographics
NPI:1558391938
Name:TERRELL, WANDA T (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:T
Last Name:TERRELL
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 1:1110 HIGHLANDS PLAZA DR E STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1351
Mailing Address - Country:US
Mailing Address - Phone:314-273-0195
Mailing Address - Fax:
Practice Address - Street 1:1110 HIGHLANDS PLAZA DR E STE 220
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1351
Practice Address - Country:US
Practice Address - Phone:314-273-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4C00207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206913113Medicaid
MO206913113Medicaid
MO990001448Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER