Provider Demographics
NPI:1912954744
Name:CORWIN, TERRY SPARK (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:SPARK
Last Name:CORWIN
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:4310 COLBY AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2338
Practice Address - Country:US
Practice Address - Phone:425-252-8102
Practice Address - Fax:425-339-0835
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040591208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA340020074OtherRAILROAD MEDICARE
WAMD00040591OtherSTATE LICENSE NUMBER
WA0160332OtherLABOR AND INDUSTRY
WA8311342Medicaid
WA8311342Medicaid
WA340020074OtherRAILROAD MEDICARE