Provider Demographics
NPI:1770524688
Name:WOLTHUIS, TERRY J (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:J
Last Name:WOLTHUIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 NORTH AVENUE SUITE 3
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-1572
Mailing Address - Country:US
Mailing Address - Phone:605-642-4656
Mailing Address - Fax:605-717-2413
Practice Address - Street 1:1230 NORTH AVENUE SUITE 3
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1572
Practice Address - Country:US
Practice Address - Phone:605-642-4656
Practice Address - Fax:605-717-2413
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT567152W00000X
SD567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203223Medicaid
SDU97877Medicare UPIN
SD9203223Medicaid