Provider Demographics
NPI:1023043163
Name:DURHAM, SUSAN LICATA (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LICATA
Last Name:DURHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10207 CERNY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7878
Mailing Address - Country:US
Mailing Address - Phone:919-361-2299
Mailing Address - Fax:919-361-0055
Practice Address - Street 1:10207 CERNY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7878
Practice Address - Country:US
Practice Address - Phone:919-361-2299
Practice Address - Fax:919-361-0055
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1335152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC410036278OtherRAILROAD MEDICARE
NC1223620002OtherPALMETTO DMERC
NCU28219Medicare UPIN
NC410036278OtherRAILROAD MEDICARE