Provider Demographics
NPI:1235249004
Name:DURHAM, JERRY CRAIG (MPT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:CRAIG
Last Name:DURHAM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6957 SARONI DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611
Mailing Address - Country:US
Mailing Address - Phone:415-509-3986
Mailing Address - Fax:
Practice Address - Street 1:3727 BUCHANAN ST
Practice Address - Street 2:#205
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123
Practice Address - Country:US
Practice Address - Phone:415-509-3986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT190390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT190390Medicare ID - Type Unspecified