Provider Demographics
NPI:1245268416
Name:POWELL, TERRY DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:DOUGLAS
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 993
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-0907
Mailing Address - Country:US
Mailing Address - Phone:620-252-1684
Mailing Address - Fax:620-252-1098
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-252-1563
Practice Address - Fax:620-252-1692
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-142322085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSA36428Medicare UPIN
KS055946POMedicare ID - Type UnspecifiedKANSAS MEDICARE