Provider Demographics
NPI:1780692053
Name:DURHAM, LARRY DAVID JR (MSPT)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DAVID
Last Name:DURHAM
Suffix:JR
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DRIVE
Mailing Address - Street 2:SUITE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262
Mailing Address - Country:US
Mailing Address - Phone:336-802-2000
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:611 N LINDSAY STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262
Practice Address - Country:US
Practice Address - Phone:336-802-2250
Practice Address - Fax:336-802-2251
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X225100000X
VA2305205060225100000X
NC12754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G4423Medicare ID - Type Unspecified
NCQ37435AMedicare PIN