Provider Demographics
NPI:1891763629
Name:DURYEA, LOIS ELAINE (DO)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:ELAINE
Last Name:DURYEA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LOIS
Other - Middle Name:ELAINE
Other - Last Name:HAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:330 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-9365
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001183A2084P0800X
IA021612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1891763629Medicaid
IA1891763629Medicaid
IAI20823Medicare PIN