Basic Information
| Provider Information | |||||||||
| NPI: | 1235103268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3165 MCCRORY PL | ||||||||
| Address2: | STE 174 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328033727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074231234 | ||||||||
| FaxNumber: | 4075171040 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 E CENTRAL PARKWY | ||||||||
| Address2: | STE 120 | ||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073317844 | ||||||||
| FaxNumber: | 4074783595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO 2241 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 390041000 | 05 | FL | MEDICAID | P00112206 | 01 | FL | R/R MEDICARE | OTHER |