Provider Demographics
NPI:1740392075
Name:DURHAM, BOOTH HAMMOND (MD)
Entity Type:Individual
Prefix:
First Name:BOOTH
Middle Name:HAMMOND
Last Name:DURHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 EGG HARBOR RD STE C1
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2359
Mailing Address - Country:US
Mailing Address - Phone:856-256-8899
Mailing Address - Fax:856-256-8868
Practice Address - Street 1:570 EGG HARBOR RD STE C1
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-256-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03237000207N00000X
PAMD021336E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740392075OtherNPI
NJ25MA03237000OtherSTATE LICENSE
C54079Medicare UPIN
NJ411689AYDMedicare ID - Type Unspecified