Provider Demographics
NPI:1104313311
Name:TERRY, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:TERRY
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 1:132 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-8107
Mailing Address - Country:US
Mailing Address - Phone:570-265-6165
Mailing Address - Fax:
Practice Address - Street 1:132 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-8107
Practice Address - Country:US
Practice Address - Phone:570-265-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT216820207Q00000X
NY312900207Q00000X
390200000X
PAMD474620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program