Provider Demographics
NPI:1689708927
Name:DURHAM, GENIA C (LDO)
Entity Type:Individual
Prefix:
First Name:GENIA
Middle Name:C
Last Name:DURHAM
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-5338
Mailing Address - Country:US
Mailing Address - Phone:423-894-2484
Mailing Address - Fax:423-894-2561
Practice Address - Street 1:5506 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5338
Practice Address - Country:US
Practice Address - Phone:423-894-2484
Practice Address - Fax:423-894-2561
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1170156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician