Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 15129 | MS |
Y | 207QS0010X | Family Doctor - Sports Medicine | 15129 | MS |
NPI | 1033137112 |
---|---|
Provider Name | Robert Edward Terrell |
First Address | Vancleave, MS 39565-6771 |
Second Address | Ocean Springs, MS 39564-5711 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 22/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00117983 | (05) | MS |
D42875 | (02) |