Provider Demographics
NPI:1922183730
Name:MENGERT, TERRY J
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:J
Last Name:MENGERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13223 NE 131ST PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3346
Mailing Address - Country:US
Mailing Address - Phone:425-941-5723
Mailing Address - Fax:425-821-8613
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023320207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
6434OtherINTERNAL ID-MOTOR VEHICLE ID
WAU32651OtherREGENCE BLUESHIELD
WA1032986Medicaid
WA1032986Medicaid
WAU32651OtherREGENCE BLUESHIELD
WAP00669960Medicare PIN