Provider Demographics
NPI:1407963515
Name:DURBIN, CONSTANCE L (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:DURBIN
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:PO BOX 1000
Mailing Address - Street 2:BOX 213
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148
Mailing Address - Country:US
Mailing Address - Phone:901-758-1980
Mailing Address - Fax:901-309-8784
Practice Address - Street 1:1135 CULLY RD
Practice Address - Street 2:STE 100
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016
Practice Address - Country:US
Practice Address - Phone:901-758-1980
Practice Address - Fax:901-309-8784
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0158472084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3088651Medicaid
3088651Medicare ID - Type Unspecified
TN3088651Medicaid