Provider Demographics
NPI:1457859886
Name:LURRY, DAVID MILTON IV
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MILTON
Last Name:LURRY
Suffix:IV
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:MILTON
Other - Last Name:LURRY
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5389 NW THYER CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3329
Mailing Address - Country:US
Mailing Address - Phone:772-204-5412
Mailing Address - Fax:
Practice Address - Street 1:5389 NW THYER CIR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3329
Practice Address - Country:US
Practice Address - Phone:772-204-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FL18-261246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty