Basic Information
| Provider Information | |||||||||
| NPI: | 1508949157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 241279 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681245279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023971531 | ||||||||
| FaxNumber: | 4023970456 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 DIAMOND ST | ||||||||
| Address2: | |||||||||
| City: | ONAWA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510401548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124232311 | ||||||||
| FaxNumber: | 7124239362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/15/2007 | ||||||||
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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 | 2085R0202X | 22564 | IA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 15071 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7914150 | 05 | IA | MEDICAID |