Provider Demographics
NPI:1629029400
Name:DURANT, MICHAEL ANDREW (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:DURANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MINI MALL DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1170
Mailing Address - Country:US
Mailing Address - Phone:859-985-0078
Mailing Address - Fax:859-985-0045
Practice Address - Street 1:116 MINI MALL DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1170
Practice Address - Country:US
Practice Address - Phone:859-985-0078
Practice Address - Fax:859-985-0045
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1345DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611344538OtherTAX ID #
KY000000064776OtherBCBS GROUP #
KY1267150001OtherPALMETTO
KY000000064780OtherBCBS
KY77013456Medicaid
KY77903276Medicaid
KY611344538OtherTAX ID #
KYU66756Medicare UPIN
KY0591901Medicare ID - Type Unspecified