Provider Demographics
NPI:1417953944
Name:DURHAM, DANIEL A (PT)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:A
Last Name:DURHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 YAKOTA DORA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-4431
Mailing Address - Country:US
Mailing Address - Phone:330-318-3957
Mailing Address - Fax:
Practice Address - Street 1:15765 STATE ROUTE 170
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9070
Practice Address - Country:US
Practice Address - Phone:330-386-5252
Practice Address - Fax:330-386-3555
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000327438OtherANTHEM BC/BS
OH2516290Medicaid
WV1064339OtherWORKERS' COMPENSATION
OH542145984OtherCARELINK COMMERICAL INS
OH542145984OtherCARELINK COMMERICAL INS
OHQ20120Medicare UPIN