Healthcare Provider Details

I. General information

NPI: 1043202856
Provider Name (Legal Business Name): MERVIN DALE TERRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W 42ND AVE
PINE BLUFF AR
71603-7109
US

IV. Provider business mailing address

1220 W 42ND AVE
PINE BLUFF AR
71603-7109
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-0013
  • Fax: 870-541-0014
Mailing address:
  • Phone: 870-541-0013
  • Fax: 870-541-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberE3820
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: