Healthcare Provider Details

I. General information

NPI: 1902434723
Provider Name (Legal Business Name): ADDISON PARKER DURHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11590 N MERIDIAN ST STE 300
CARMEL IN
46032-4529
US

IV. Provider business mailing address

11590 N MERIDIAN ST STE 300
CARMEL IN
46032-4529
US

V. Phone/Fax

Practice location:
  • Phone: 317-948-5450
  • Fax:
Mailing address:
  • Phone: 317-948-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number6473
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: