Provider Demographics
NPI:1023054343
Name:BURDICK, MALCOLM ROGER (PHD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:ROGER
Last Name:BURDICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-4710
Mailing Address - Country:US
Mailing Address - Phone:972-291-8368
Mailing Address - Fax:
Practice Address - Street 1:8059 SCYENE CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5562
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86979AOtherBLUE CROSS BLUE SHIELD
TX170349802Medicaid
TX170349803Medicaid
TX170349801Medicaid
TX170349803Medicaid
TX8C9543Medicare ID - Type Unspecified
TX170349801Medicaid