Provider Demographics
NPI:1609812767
Name:DURAK, GARY M (PH D)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:DURAK
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 NAPOLEON ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4725
Mailing Address - Country:US
Mailing Address - Phone:219-464-7678
Mailing Address - Fax:219-464-0941
Practice Address - Street 1:7 NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4725
Practice Address - Country:US
Practice Address - Phone:219-464-7678
Practice Address - Fax:219-464-0941
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090233A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP57840001OtherPTAN
656530Medicare ID - Type Unspecified