Healthcare Provider Details

I. General information

NPI: 1295823631
Provider Name (Legal Business Name): TERRY ALLEN IWASKO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 MAIN ST STE 110
INDIANAPOLIS IN
46224-6978
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-9150
  • Fax: 317-957-9965
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02001352
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: