Provider Demographics
NPI:1558354761
Name:DURHAM, JON KENNETH
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:KENNETH
Last Name:DURHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1921
Mailing Address - Country:US
Mailing Address - Phone:229-883-3535
Mailing Address - Fax:229-883-3783
Practice Address - Street 1:531 7TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1921
Practice Address - Country:US
Practice Address - Phone:229-883-3535
Practice Address - Fax:229-883-3783
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000522213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00301232AMedicaid
$$$$$$$$$AMedicare PIN
GAT97553Medicare UPIN
0783570001Medicare NSC