Provider Demographics
NPI:1801803044
Name:MARQUARDT, TERRY TYRONE (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:TYRONE
Last Name:MARQUARDT
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 1:903 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6919
Mailing Address - Country:US
Mailing Address - Phone:575-437-7783
Mailing Address - Fax:575-439-0615
Practice Address - Street 1:903 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6919
Practice Address - Country:US
Practice Address - Phone:575-437-7783
Practice Address - Fax:575-439-0615
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM233152W00000X
TX05843TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000P6299Medicaid
NMNM00P012OtherBLUE CROSS BLUE SHIELD
NM540004536OtherRR MEDICARE
NM540004536OtherRR MEDICARE
NMNM00P012OtherBLUE CROSS BLUE SHIELD
NM2506506Medicare PIN