Provider Demographics
NPI:1710089925
Name:TERRY, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:58 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1336
Mailing Address - Country:US
Mailing Address - Phone:570-724-7477
Mailing Address - Fax:570-724-3046
Practice Address - Street 1:58 WEST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1336
Practice Address - Country:US
Practice Address - Phone:570-724-7477
Practice Address - Fax:570-724-3046
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021101E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007909280003Medicaid
C28948Medicare UPIN
PA0007909280003Medicaid