Provider Demographics
NPI:1154433720
Name:DETRICH, TERRY (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:DETRICH
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 1:29466 PINTAIL DR STE 10
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-9324
Mailing Address - Country:US
Mailing Address - Phone:443-746-3816
Mailing Address - Fax:410-604-7349
Practice Address - Street 1:29466 PINTAIL DR STE 10
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-9324
Practice Address - Country:US
Practice Address - Phone:443-746-3816
Practice Address - Fax:410-604-7349
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD128932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD41274801OtherBLUE SHIELD
MD41274801OtherBLUE SHIELD
MD41274801OtherBLUE SHIELD
MD031581800Medicaid