Provider Demographics
NPI:1477743078
Name:DURST, JAN WILLIAM
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:WILLIAM
Last Name:DURST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:1075 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1288
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:812-476-1016
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY002363OtherKENTUCKY STATE LICENSE
KY00807003Medicare PIN
KYP00796273Medicare UPIN