Provider Demographics
NPI:1144712902
Name:TERRY, KENNETH DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:TERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E MOUNTAIN VIEW ST STE F
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3052
Mailing Address - Country:US
Mailing Address - Phone:760-256-1777
Mailing Address - Fax:
Practice Address - Street 1:500 S 7TH AVE STE B&C
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3056
Practice Address - Country:US
Practice Address - Phone:760-256-1777
Practice Address - Fax:760-256-7766
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16604207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine