1235103268 NPI number — JOHN G. DURHAM DPM

Table of content: JOHN G. DURHAM DPM (NPI 1235103268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235103268 NPI number — JOHN G. DURHAM DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURHAM
Provider First Name:
JOHN
Provider Middle Name:
G.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235103268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3165 MCCRORY PL
Provider Second Line Business Mailing Address:
STE 174
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32803-3727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-423-1234
Provider Business Mailing Address Fax Number:
407-517-1040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 E CENTRAL PARKWY
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-331-7844
Provider Business Practice Location Address Fax Number:
407-478-3595
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO 2241 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 390041000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00112206 . This is a "R/R MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 390041000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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