Healthcare Provider Details

I. General information

NPI: 1114210085
Provider Name (Legal Business Name): MARISA JEAN TERRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 RIVERSIDE PLAZA LN NW STE 100
ALBUQUERQUE NM
87120-2682
US

IV. Provider business mailing address

PO BOX 734951
CHICAGO IL
60673-4951
US

V. Phone/Fax

Practice location:
  • Phone: 505-322-6687
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME127530
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number55801
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: