Provider Demographics
NPI:1366409021
Name:TERK, MITCHELL D (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:D
Last Name:TERK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 A C SKINNER PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-520-6800
Mailing Address - Fax:904-520-6801
Practice Address - Street 1:710 LOMAX ST
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4004
Practice Address - Country:US
Practice Address - Phone:904-483-2310
Practice Address - Fax:904-483-2313
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME739252085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL226458OtherAVMED
FL255850500Medicaid
FLP00191302OtherRAILROAD MEDICARE
FL42370OtherBCBS
FL42370QMedicare PIN
FL42370MMedicare PIN
FL42370RMedicare PIN
FLAJ031UMedicare PIN
FL42370KMedicare PIN
FL42370OtherBCBS
FLAJ031WMedicare PIN
FL226458OtherAVMED
FL255850500Medicaid
FLAJ031SMedicare PIN
FLAJ031RMedicare PIN