Healthcare Provider Details

I. General information

NPI: 1255549010
Provider Name (Legal Business Name): MELVIN ANTHONY TERRY P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TANG CTR 2222 BANCROFT WAY
BERKELEY CA
94720-4300
US

IV. Provider business mailing address

2181 MAGELLAN DR
OAKLAND CA
94611-2639
US

V. Phone/Fax

Practice location:
  • Phone: 510-543-0697
  • Fax: 510-643-5079
Mailing address:
  • Phone: 510-339-6033
  • Fax: 302-336-6033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT7882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: