Provider Demographics
NPI:1487604278
Name:BURCHETT, GAIL D (DO)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:D
Last Name:BURCHETT
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 1:35 ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2963
Mailing Address - Country:US
Mailing Address - Phone:719-564-4618
Mailing Address - Fax:480-393-0935
Practice Address - Street 1:35 ALTADENA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2963
Practice Address - Country:US
Practice Address - Phone:719-564-4618
Practice Address - Fax:480-393-0935
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC21178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01211788Medicaid
CO01211788Medicaid
COC2102Medicare PIN