Provider Demographics
NPI:1326005190
Name:DURHAM, MICHEAL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHEAL
Middle Name:J
Last Name:DURHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1930 N BUSINESS ROUTE 5
Mailing Address - Street 2:UNIT 1A
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2659
Mailing Address - Country:US
Mailing Address - Phone:573-346-5624
Mailing Address - Fax:573-346-1957
Practice Address - Street 1:1930 N BUSINESS ROUTE 5
Practice Address - Street 2:UNIT 1A
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2659
Practice Address - Country:US
Practice Address - Phone:573-346-5624
Practice Address - Fax:573-346-1957
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4291207Q00000X
MO2010019729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1326005190Medicaid