Provider Demographics
NPI:1811262280
Name:DRAKE, TERRANCE STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:STEPHEN
Last Name:DRAKE
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 1:5563 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3473
Mailing Address - Country:US
Mailing Address - Phone:801-216-4581
Mailing Address - Fax:
Practice Address - Street 1:5563 COVENTRY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3473
Practice Address - Country:US
Practice Address - Phone:801-216-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7584822-1205207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine