Provider Demographics
NPI:1700995438
Name:HIMES, TERRY MARK (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:MARK
Last Name:HIMES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 GARDEN ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5285
Mailing Address - Country:US
Mailing Address - Phone:702-482-4551
Mailing Address - Fax:
Practice Address - Street 1:243 GARDEN ARBOR CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5285
Practice Address - Country:US
Practice Address - Phone:702-482-4551
Practice Address - Fax:308-631-7979
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE622084N0400X
MT799562084N0400X
IN02005730A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41631OtherCOLORADO STATE LICENSE
NE10024983100Medicaid
CO71288333 -INDIVIDUALMedicaid
NE099331Medicare ID - Type Unspecified
NE10024983100Medicaid
NEB90893Medicare UPIN
COC811520-INDIV CNSCMedicare PIN