Provider Demographics
NPI:1609881333
Name:DURYEA, KATHLEEN A (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:DURYEA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:391 NORTHWOOD DR
Practice Address - Street 2:
Practice Address - City:CENTRE
Practice Address - State:AL
Practice Address - Zip Code:35960-1020
Practice Address - Country:US
Practice Address - Phone:256-927-7412
Practice Address - Fax:256-927-7416
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA169657986AMedicaid
AL009937532Medicaid
AL051557506Medicare PIN
GA169657986AMedicaid