Provider Demographics
NPI:1255706503
Name:DURHAM, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DURHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6142 FURNACE RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-8901
Mailing Address - Country:US
Mailing Address - Phone:315-333-5145
Mailing Address - Fax:
Practice Address - Street 1:6142 FURNACE RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-8901
Practice Address - Country:US
Practice Address - Phone:315-333-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210632-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse