Provider Demographics
NPI:1760540215
Name:DURIS, JERRY FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:FRED
Last Name:DURIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2188
Mailing Address - Country:US
Mailing Address - Phone:253-848-5951
Mailing Address - Fax:253-845-7073
Practice Address - Street 1:800 S MERIDIAN
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-6995
Practice Address - Country:US
Practice Address - Phone:253-845-6645
Practice Address - Fax:253-770-2295
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110099728OtherMEDICARE OTHER-INDIVIDUAL
WA1052802Medicaid
WACO3401OtherMEDICARE OTHER-GROUP
WAG001001778Medicare PIN
WAC92551Medicare UPIN