Provider Demographics
NPI:1043279268
Name:TERRY, GERALDINE J (MD)
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:J
Last Name:TERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13438 FORT KING RD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-5214
Mailing Address - Country:US
Mailing Address - Phone:352-567-5266
Mailing Address - Fax:352-567-3066
Practice Address - Street 1:1651 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:407-249-1755
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100533208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043279268OtherNPI
FL280829300Medicaid
FL280829300Medicaid