Provider Demographics
NPI:1124070271
Name:DURAND, PHILLIP WAYNE (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WAYNE
Last Name:DURAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12687 W CEDAR DR
Mailing Address - Street 2:200
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2010
Mailing Address - Country:US
Mailing Address - Phone:575-623-4844
Mailing Address - Fax:575-625-9951
Practice Address - Street 1:12687 W CEDAR DR
Practice Address - Street 2:200
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2010
Practice Address - Country:US
Practice Address - Phone:575-623-4844
Practice Address - Fax:575-625-9951
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-922-902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF7074Medicaid
C52050Medicare UPIN
NMF7074Medicaid