Provider Demographics
NPI:1124342738
Name:TERRY, RICHARD N (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:N
Last Name:TERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-560-3700
Mailing Address - Fax:262-569-2206
Practice Address - Street 1:1284 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-560-3700
Practice Address - Fax:262-569-2206
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56872-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124342738Medicaid
WI100030502Medicaid
WI736012740Medicare PIN