Healthcare Provider Details

I. General information

NPI: 1487640884
Provider Name (Legal Business Name): EDOUARD J DURET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 1ST AVE N
ILWACO WA
98624
US

IV. Provider business mailing address

176 1ST AVE N PO DRAWER N
ILWACO WA
98624
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3747
  • Fax: 360-642-3361
Mailing address:
  • Phone: 360-642-3747
  • Fax: 360-642-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00036757
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: