Provider Demographics
NPI:1871973198
Name:TERRY, BRADLEY WESCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WESCOTT
Last Name:TERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 W 940 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3301
Mailing Address - Country:US
Mailing Address - Phone:801-357-7940
Mailing Address - Fax:
Practice Address - Street 1:360 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2261
Practice Address - Country:US
Practice Address - Phone:208-549-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9832809-1204207Q00000X
390200000X
IDO-1122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program