Provider Demographics
NPI:1235247917
Name:MIDURE, GUY D (ATC)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:D
Last Name:MIDURE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD WORKS
Mailing Address - State:NJ
Mailing Address - Zip Code:08089-2230
Mailing Address - Country:US
Mailing Address - Phone:856-768-3693
Mailing Address - Fax:
Practice Address - Street 1:625 BREAKNECK RD
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-2421
Practice Address - Country:US
Practice Address - Phone:856-223-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMT008072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer