Basic Information
| Provider Information | |||||||||
| NPI: | 1760498737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | #200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138202 | ||||||||
| FaxNumber: | 5034136937 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | #200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138202 | ||||||||
| FaxNumber: | 5034136937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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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 | 207W00000X | MD17016 | OR | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 016514 | 05 | OR | MEDICAID |