Healthcare Provider Details

I. General information

NPI: 1750692570
Provider Name (Legal Business Name): RENATO M DURHAM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 W EAU GALLIE BLVD
MELBOURNE FL
32935-3185
US

IV. Provider business mailing address

2080 W EAU GALLIE BLVD
MELBOURNE FL
32935-3185
US

V. Phone/Fax

Practice location:
  • Phone: 321-254-6218
  • Fax: 321-254-6230
Mailing address:
  • Phone: 321-254-6218
  • Fax: 321-254-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME67647
License Number StateFL

VIII. Authorized Official

Name: RENATO M DURHAM
Title or Position: PRESIDENT
Credential: MD
Phone: 321-254-6218