Provider Demographics
NPI:1649228446
Name:TERRY, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:531 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2450
Mailing Address - Country:US
Mailing Address - Phone:208-743-4393
Mailing Address - Fax:208-743-4214
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-799-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000175472085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0227614OtherDLI
IDP00468202OtherTRAVELERS/RAILROAD MEDICARE
WA8255408Medicaid
ID003973900Medicaid
ID77142OtherBLUE CROSS OF IDAHO
ID000010165165OtherREGENCE BLUE SHIELD OF IDAHO
WA0227614OtherDLI
IDA36374Medicare UPIN