Provider Demographics
NPI:1730165820
Name:DEAN, TERRY LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LYNN
Last Name:DEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N JUNIPER PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-1540
Mailing Address - Country:US
Mailing Address - Phone:918-258-6519
Mailing Address - Fax:
Practice Address - Street 1:17675 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5492
Practice Address - Country:US
Practice Address - Phone:918-453-5387
Practice Address - Fax:918-458-6159
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17917208D00000X
MOR2G69208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1117917Medicaid
OK8EZ75MMedicare ID - Type UnspecifiedJAY
OK1117917Medicaid
OKG07499Medicare UPIN
OK8EZ70MMedicare ID - Type UnspecifiedSTILWELL
OK8EZ74MMedicare ID - Type UnspecifiedNOWATA
OK8EZ72MMedicare ID - Type UnspecifiedMUSKOGEE
OK8EA73MMedicare ID - Type UnspecifiedSALINA