Provider Demographics
NPI:1801412911
Name:MABRY, TERRANCE CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:CHRISTIAN
Last Name:MABRY
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 1:40100 US HWY 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837
Mailing Address - Country:US
Mailing Address - Phone:314-307-9194
Mailing Address - Fax:
Practice Address - Street 1:40100 US HWY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837
Practice Address - Country:US
Practice Address - Phone:863-419-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013133207R00000X
FLME160716207R00000X
KS04-47700207R00000X
MO2021044514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine