1225233729 NPI number — WILLIAM ELTON BURNETT D.O

Table of content: WILLIAM ELTON BURNETT D.O (NPI 1225233729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225233729 NPI number — WILLIAM ELTON BURNETT D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNETT
Provider First Name:
WILLIAM
Provider Middle Name:
ELTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225233729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2720 MALL OF GEORGIA BLVD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30519-8761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-697-6695
Provider Business Mailing Address Fax Number:
678-957-0887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 BOGGS RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-5890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-697-6695
Provider Business Practice Location Address Fax Number:
678-957-0887
Provider Enumeration Date:
06/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  020413 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00208392A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com