Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1800X | Optician | LDO002227 | GA |
NPI | 1235431495 |
---|---|
Provider Name | Dr. Charles Wesley Durham |
First Address | Sterling, VA 20164-5367 |
Second Address | Sterling, VA 20164-5367 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2010 |
Last Update Date | 12/02/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0202212968 | STATE LICENSE (01) | VA |
LDO002227 | STATE LICENSE (01) | GA |
PHI-015156 | STATE LICENSE (01) | GA |