Provider Demographics
NPI:1376562942
Name:DURHAM, JOHN DEREK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DEREK
Last Name:DURHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1128 CLARKSVILLE ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-6060
Mailing Address - Country:US
Mailing Address - Phone:903-785-4362
Mailing Address - Fax:903-782-9365
Practice Address - Street 1:1128 CLARKSVILLE ST
Practice Address - Street 2:STE. 100
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-6060
Practice Address - Country:US
Practice Address - Phone:903-785-4362
Practice Address - Fax:903-782-9365
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK3572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080179154OtherINDIVIDUAL RAILROAD MC
TX124500OtherSUPERIOR
TX8B5721OtherINDIVIDUAL BLUE CROSS
TX144831802OtherGROUP TEXAS HEALTH STEPS
TX047352202Medicaid
TX5967628OtherAETNA
TX8B5721OtherINDIVIDUAL BLUE CROSS
TXG70808Medicare UPIN