Provider Demographics
NPI:1598842031
Name:DURDEN, CHARLES HENRY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
Last Name:DURDEN
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:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-0480
Mailing Address - Country:US
Mailing Address - Phone:229-423-4333
Mailing Address - Fax:229-423-0928
Practice Address - Street 1:110 NORMAN DORMINY DR
Practice Address - Street 2:SUITE A
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8858
Practice Address - Country:US
Practice Address - Phone:229-423-4333
Practice Address - Fax:229-423-0928
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00015056AMedicaid
GAD29351Medicare UPIN
GA00015056AMedicaid