Provider Demographics
NPI:1962497230
Name:TERRYBERRY, DANIEL S (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:TERRYBERRY
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 1:1141 N ROAD ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3354
Mailing Address - Country:US
Mailing Address - Phone:252-335-5424
Mailing Address - Fax:252-334-1501
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:SUITE G
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-335-5424
Practice Address - Fax:252-334-1501
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2008-12-09
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NC35532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC82438OtherBC/BS OF NC PROV #
NC89-82438Medicaid
NY272562OtherMAMSI / ALLIANCE PROV #
NY272562OtherMAMSI / ALLIANCE PROV #
NC89-82438Medicaid