Provider Demographics
NPI:1861733008
Name:TERRY W DURHAM OD PSC
Entity type:Organization
Organization Name:TERRY W DURHAM OD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD PSC
Authorized Official - Phone:270-651-3466
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1021DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010213Medicaid
KYT54704Medicare UPIN
KY9211601Medicare Oscar/Certification