Provider Demographics
NPI:1174554745
Name:DURHAM, RENATO M (MD)
Entity type:Individual
Prefix:DR
First Name:RENATO
Middle Name:M
Last Name:DURHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-8182
Practice Address - Country:US
Practice Address - Phone:574-583-1785
Practice Address - Fax:317-968-1321
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067647207P00000X
IN01067412A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG08058Medicare UPIN
FL27333Medicare ID - Type Unspecified