Healthcare Provider Details

I. General information

NPI: 1417946591
Provider Name (Legal Business Name): RAYMOND HOWARD DURUSSEL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY. 491 NORTH
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

PO BOX 160 US HWY 491 NORTH
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6651
  • Fax: 505-368-7078
Mailing address:
  • Phone: 505-368-6651
  • Fax: 505-368-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number5901001395
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0333
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0328
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: