Provider Demographics
NPI:1871607424
Name:EXSTRUM, TERRY DALE (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:DALE
Last Name:EXSTRUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4708 ALLIANCE BLVD STE 300
Mailing Address - Street 2:BAYLOR MEDICAL PLAZA 1
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5339
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD STE 300
Practice Address - Street 2:BAYLOR MEDICAL PLAZA 1
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5339
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8140207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043126401Medicaid
TX0431264-02Medicaid
TX87195SOtherBCBS
TX460002517Medicare PIN
TX0431264-02Medicaid
TX043126401Medicaid
TX84615NMedicare PIN
TXG93668Medicare UPIN