Provider Demographics
NPI:1457377517
Name:TERRELL, MWATABU (MD)
Entity Type:Individual
Prefix:
First Name:MWATABU
Middle Name:
Last Name:TERRELL
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 1:3101 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4849
Mailing Address - Country:US
Mailing Address - Phone:704-376-7362
Mailing Address - Fax:
Practice Address - Street 1:3101 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4849
Practice Address - Country:US
Practice Address - Phone:704-376-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ00976Medicaid
NC891295KMedicaid
NC891295KMedicaid
SCQ00976Medicaid