Basic Information
| Provider Information | |||||||||
| NPI: | 1326005190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | MICHEAL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 N BUSINESS ROUTE 5 | ||||||||
| Address2: | UNIT 1A | ||||||||
| City: | CAMDENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650202659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733465624 | ||||||||
| FaxNumber: | 5733461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 N BUSINESS ROUTE 5 | ||||||||
| Address2: | UNIT 1A | ||||||||
| City: | CAMDENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650202659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733465624 | ||||||||
| FaxNumber: | 5733461957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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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 | 207Q00000X | 4291 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2010019729 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1326005190 | 05 | MO | MEDICAID |