Provider Demographics
NPI:1205901378
Name:DURICA, JON M (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:DURICA
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 1:1275 SUMMER ST
Mailing Address - Street 2:SUTEI 301
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5359
Mailing Address - Country:US
Mailing Address - Phone:203-324-4100
Mailing Address - Fax:203-324-8539
Practice Address - Street 1:1275 SUMMER ST
Practice Address - Street 2:SUITE 301
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5359
Practice Address - Country:US
Practice Address - Phone:203-324-4100
Practice Address - Fax:203-324-8539
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010032876CT02OtherBLUE CROSS-DARIEN
CT10444182OtherCAQH
CT703287OtherCONNECTICARE
CT022213OtherHEALTHNET
CT010032876CT01OtherBLUE CROSS-STAMFORD
CT4344937OtherAETNA
CTZP302OtherOXFORD
CT10444182OtherCAQH