Basic Information
Provider Information | |||||||||
NPI: | 1689774408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DURHAM-WORTHINGTON | ||||||||
FirstName: | JANICE | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DURHAM | ||||||||
OtherFirstName: | JANICE | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 94-1480 MOANIANI ST | ||||||||
Address2: |   | ||||||||
City: | WAIPAHU | ||||||||
State: | HI | ||||||||
PostalCode: | 967974632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084323100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 94-1480 MOANIANI ST | ||||||||
Address2: |   | ||||||||
City: | WAIPAHU | ||||||||
State: | HI | ||||||||
PostalCode: | 967974632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084323100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 10/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD-271 | HI | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 041348-02 | 05 | HI |   | MEDICAID | 0000045492 | 01 | HI | HMSA BILLING NUMBER | OTHER |