Healthcare Provider Details

I. General information

NPI: 1689986275
Provider Name (Legal Business Name): JUSTIN DANIEL TERRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N MAIN ST
GRAVOIS MILLS MO
65037-6253
US

IV. Provider business mailing address

401 N MAIN ST
GRAVOIS MILLS MO
65037-6253
US

V. Phone/Fax

Practice location:
  • Phone: 877-406-2662
  • Fax: 573-207-2773
Mailing address:
  • Phone: 877-406-2662
  • Fax: 573-207-2773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013026811
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: