Provider Demographics
NPI:1366892846
Name:BURNETT, JOHN JAMES (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:BURNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3300
Mailing Address - Country:US
Mailing Address - Phone:315-629-4525
Mailing Address - Fax:315-629-5751
Practice Address - Street 1:26908 INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3300
Practice Address - Country:US
Practice Address - Phone:315-629-4525
Practice Address - Fax:315-629-5751
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300258207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05863332Medicaid