Provider Demographics
NPI:1134350226
Name:TERRY, CHRISTOPHER ROBERT (IDC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:TERRY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 TRIDENT WAY
Mailing Address - Street 2:
Mailing Address - City:CORANADO
Mailing Address - State:CA
Mailing Address - Zip Code:92155
Mailing Address - Country:US
Mailing Address - Phone:619-537-2361
Mailing Address - Fax:
Practice Address - Street 1:2446 TRIDENT WAY
Practice Address - Street 2:
Practice Address - City:CORANADO
Practice Address - State:CA
Practice Address - Zip Code:92155
Practice Address - Country:US
Practice Address - Phone:619-537-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA08983OtherCERTIFICATE OF GRADUATION, NAVAL SCHOOL OF HEALTH SCIENCES