Basic Information
| Provider Information | |||||||||
| NPI: | 1487654836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORING | ||||||||
| FirstName: | TERRENCE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 N MONTE VISTA | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367101 | ||||||||
| FaxNumber: | 5804364447 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 ARLINGTON | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803329100 | ||||||||
| FaxNumber: | 5803328554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11690 | OK | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100208560A | 05 | OK | MEDICAID |