Provider Demographics
NPI:1699043976
Name:TRAVIS, TERRY ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:ARTHUR
Last Name:TRAVIS
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 1:1200 RAVENSWOOD
Mailing Address - Street 2:NA
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6079
Mailing Address - Country:US
Mailing Address - Phone:217-899-6229
Mailing Address - Fax:
Practice Address - Street 1:1200 RAVENSWOOD
Practice Address - Street 2:NA
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6079
Practice Address - Country:US
Practice Address - Phone:217-899-6229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.0467272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry