| Doctor Name: | MR. WADE THOMAS DURHAM |
| NPI Number: | 1972695104 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | OPTICIAN |
| License Number: | DO 1085 |
| Business Practice Address: | 940 N Main St Bushnell, FL - 335135008 |
| Business Phone Number: | 3525680442 |
| Business Fax Number: | 3525682902 |
| Mailing Address: | 807 Crestview Cir N, WILDWOOD |
| State: | FL |
| Postal Code: | 347853535 |
| Phone Number: | 3523300226 |
| Fax Number: | 3525682902 |
| NPI Enumeration Date: | 09/28/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | DO 1085 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |