Provider Demographics
NPI:1720139116
Name:MACCONNELL, TERENCE PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:TERENCE
Middle Name:PHILLIP
Last Name:MACCONNELL
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 1:300 TERRY LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-8539
Mailing Address - Country:US
Mailing Address - Phone:512-259-2725
Mailing Address - Fax:
Practice Address - Street 1:13831 N HIGHWAY 183
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1202
Practice Address - Country:US
Practice Address - Phone:512-250-0424
Practice Address - Fax:512-219-0192
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4494208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24543Medicare UPIN