Healthcare Provider Details

I. General information

NPI: 1144712902
Provider Name (Legal Business Name): KENNETH DAVID TERRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E BUENA VISTA ST
BARSTOW CA
92311-2803
US

IV. Provider business mailing address

303 E BUENA VISTA ST
BARSTOW CA
92311-2803
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-4929
  • Fax: 760-241-5950
Mailing address:
  • Phone: 760-241-4929
  • Fax: 760-241-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A16604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: