Provider Demographics
NPI:1821162587
Name:CORRELL, TERRY LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:CORRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG
Mailing Address - Street 2:4881 SUGAR MAPLE DR.
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-938-2768
Mailing Address - Fax:937-904-8753
Practice Address - Street 1:88 MDG
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-938-2768
Practice Address - Fax:937-904-8753
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6456-C2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCO7265251Medicare ID - Type UnspecifiedMEDICARE (HCFA)