Provider Demographics
NPI:1174735500
Name:BURGESS, BURL R (OD)
Entity type:Individual
Prefix:DR
First Name:BURL
Middle Name:R
Last Name:BURGESS
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 1:2576 S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9120
Mailing Address - Country:US
Mailing Address - Phone:386-774-6000
Mailing Address - Fax:386-774-6971
Practice Address - Street 1:2576 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9120
Practice Address - Country:US
Practice Address - Phone:386-774-6000
Practice Address - Fax:386-774-6971
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19360Medicare ID - Type Unspecified
FLT93836Medicare UPIN