Provider Demographics
NPI:1356337851
Name:FALL, TERRY L (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:FALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6190 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6969
Mailing Address - Country:US
Mailing Address - Phone:850-476-9236
Mailing Address - Fax:850-471-0557
Practice Address - Street 1:6190 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6969
Practice Address - Country:US
Practice Address - Phone:850-476-9236
Practice Address - Fax:850-471-0557
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2621152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U65166Medicare UPIN
FL20717ZMedicare ID - Type Unspecified