Provider Demographics
NPI:1114025665
Name:NULL, TERRY N (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:N
Last Name:NULL
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13840 E 96TH ST
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9394
Mailing Address - Country:US
Mailing Address - Phone:317-720-2020
Mailing Address - Fax:317-458-1594
Practice Address - Street 1:13840 E 96TH ST
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9394
Practice Address - Country:US
Practice Address - Phone:317-720-2020
Practice Address - Fax:317-458-1594
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002112A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T93584Medicare UPIN
IN1205720003Medicare NSC
IN675840DMedicare ID - Type Unspecified