Basic Information
Provider Information | |||||||||
NPI: | 1427212414 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DURNAN | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 920 REVOLUTION ST | ||||||||
Address2: |   | ||||||||
City: | HAVRE DE GRACE | ||||||||
State: | MD | ||||||||
PostalCode: | 210783748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109392200 | ||||||||
FaxNumber: | 4109395980 | ||||||||
Practice Location | |||||||||
Address1: | 360 E PULASKI HWY STE 1B | ||||||||
Address2: |   | ||||||||
City: | ELKTON | ||||||||
State: | MD | ||||||||
PostalCode: | 219216592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103985240 | ||||||||
FaxNumber: | 4103984762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2008 | ||||||||
LastUpdateDate: | 04/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2100 | MD | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.