Basic Information
| Provider Information | |||||||||
| NPI: | 1366892606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERHARK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5016 S US HIGHWAY 75 | ||||||||
| Address2: | |||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750205207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034164000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1528 W DAY ST | ||||||||
| Address2: | |||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750205207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529947464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2016 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10058109 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | R4485 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BP10058109 | 01 | TX | PHYSICIAN IN TRAINING | OTHER |