Provider Demographics
NPI:1770742777
Name:DURHAM OPTICAL, INC
Entity type:Organization
Organization Name:DURHAM OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WADE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:352-568-0442
Mailing Address - Street 1:940 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-5008
Mailing Address - Country:US
Mailing Address - Phone:352-568-0442
Mailing Address - Fax:352-568-2902
Practice Address - Street 1:940 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-5008
Practice Address - Country:US
Practice Address - Phone:352-568-0442
Practice Address - Fax:352-568-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO1085156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086841800Medicaid
FL0870330001Medicare UPIN