1013194281 NPI number — CURTIS D. BURGHART, OD, PS

Table of content: (NPI 1013194281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013194281 NPI number — CURTIS D. BURGHART, OD, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CURTIS D. BURGHART, OD, PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013194281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1203 S GOLD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531-3715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-736-4203
Provider Business Mailing Address Fax Number:
360-736-7059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1203 S GOLD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-3715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-736-4203
Provider Business Practice Location Address Fax Number:
360-736-7059
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BURGHART
Authorized Official First Name:
CURTIS
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-736-4203

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1838 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2013225 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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