Healthcare Provider Details

I. General information

NPI: 1023043163
Provider Name (Legal Business Name): SUSAN LICATA DURHAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10207 CERNY ST SUITE 100
RALEIGH NC
27617-7878
US

IV. Provider business mailing address

10207 CERNY ST SUITE 100
RALEIGH NC
27617-7878
US

V. Phone/Fax

Practice location:
  • Phone: 919-361-2299
  • Fax: 919-361-0055
Mailing address:
  • Phone: 919-361-2299
  • Fax: 919-361-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1335
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1335
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1335
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number1335
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1335
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: