Provider Demographics
NPI:1720151756
Name:DURHAM, TERRY W (OD PSC)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:W
Last Name:DURHAM
Suffix:
Gender:M
Credentials:OD PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-2426
Mailing Address - Country:US
Mailing Address - Phone:270-651-3466
Mailing Address - Fax:270-659-0633
Practice Address - Street 1:218 S LIBERTY ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2426
Practice Address - Country:US
Practice Address - Phone:270-651-3466
Practice Address - Fax:270-659-0633
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1021DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010213Medicaid
KY77010213Medicaid
KYT54704Medicare UPIN
KY9211601Medicare ID - Type Unspecified