Healthcare Provider Details

I. General information

NPI: 1083460901
Provider Name (Legal Business Name): TREY DURHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number82023-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number82023-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: