Provider Demographics
NPI:1750379368
Name:DURHAM, JEREMY M (OD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:M
Last Name:DURHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 N TYLER RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-3630
Mailing Address - Country:US
Mailing Address - Phone:316-722-1001
Mailing Address - Fax:316-722-1073
Practice Address - Street 1:437 N TYLER RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3630
Practice Address - Country:US
Practice Address - Phone:316-722-1001
Practice Address - Fax:316-722-1073
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200333580AMedicaid
KS650938OtherBLUE CROSS
KS0803320001OtherDMERC
KS650938OtherBLUE CROSS
KS650938Medicare ID - Type Unspecified
KS48-1122524OtherTAX ID NUMBER