Basic Information
Provider Information | |||||||||
NPI: | 1043279268 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TERRY | ||||||||
FirstName: | GERALDINE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13438 FORT KING RD | ||||||||
Address2: |   | ||||||||
City: | DADE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 335255214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525675266 | ||||||||
FaxNumber: | 3525673066 | ||||||||
Practice Location | |||||||||
Address1: | 1651 N SEMORAN BLVD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 32807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072491234 | ||||||||
FaxNumber: | 4072491755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2006 | ||||||||
LastUpdateDate: | 10/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME100533 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1043279268 | 01 |   | NPI | OTHER | 280829300 | 05 | FL |   | MEDICAID |