Provider Demographics
NPI:1053615781
Name:DURHAM, MARK EDWARD (RMT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:DURHAM
Suffix:
Gender:M
Credentials:RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 RAMSGATE TER
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3175
Mailing Address - Country:US
Mailing Address - Phone:719-233-0213
Mailing Address - Fax:
Practice Address - Street 1:2208 RAMSGATE TER
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3175
Practice Address - Country:US
Practice Address - Phone:719-233-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist