Provider Demographics
NPI:1922595990
Name:BURNSIDE, CONNOR (DO)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:BURNSIDE
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 1:2080 MEADOWLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 MEADOWLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4326
Practice Address - Country:US
Practice Address - Phone:863-701-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS188282084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry