Basic Information
| Provider Information | |||||||||
| NPI: | 1891767141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 N TURQUOISE DRIVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747757 | ||||||||
| FaxNumber: | 9282263071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 N TURQUOISE DRIVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747757 | ||||||||
| FaxNumber: | 9282263071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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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 | 174400000X | 21077 | AZ | N | Other Service Providers | Specialist | 207X00000X | 21077 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 21077 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 118572 | 05 | AZ | MEDICAID |