Provider Demographics
NPI:1295775815
Name:TERRY, MAX L (MD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:L
Last Name:TERRY
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 1:2110 AIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3652
Mailing Address - Country:US
Mailing Address - Phone:928-681-1800
Mailing Address - Fax:928-681-1832
Practice Address - Street 1:2110 AIRWAY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3652
Practice Address - Country:US
Practice Address - Phone:928-681-1800
Practice Address - Fax:928-681-1832
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ842501Medicaid
AZAZ0749420OtherBLUE SHIELD ARIZONA
AZ78356Medicare ID - Type Unspecified
AZ842501Medicaid