Healthcare Provider Details

I. General information

NPI: 1366409021
Provider Name (Legal Business Name): MITCHELL D TERK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LOMAX ST SUITE 1
JACKSONVILLE FL
32204-4004
US

IV. Provider business mailing address

7017 A C SKINNER PKWY
JACKSONVILLE FL
32256-6932
US

V. Phone/Fax

Practice location:
  • Phone: 904-483-2310
  • Fax: 904-483-2313
Mailing address:
  • Phone: 904-520-6800
  • Fax: 904-520-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME73925
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: