Individual
MARK A TERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
415 6TH ST, LEWISTON, ID 83501-2431
(208) 799-5335
Mailing address
531 4TH AVE, LEWISTON, ID 83501-2450
(208) 743-4393
(208) 743-4214
Taxonomy
Speciality
Code
Description
License number
State
2085R0205X
Radiological Physics Physician
Primary
MD00017547
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010165165
REGENCE BLUE SHIELD OF IDAHO
ID
05
—
003973900
—
ID
01
—
0227614
DLI
WA
01
—
77142
BLUE CROSS OF IDAHO
ID
05
—
8255408
—
WA
01
—
P00468202
TRAVELERS/RAILROAD MEDICARE
ID
Enumeration date
05/04/2006
Last updated
11/05/2008
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