1235236316 NPI number — MARK BURNISTON M.D.

Table of content: MARK BURNISTON M.D. (NPI 1235236316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235236316 NPI number — MARK BURNISTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNISTON
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1235236316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10470 OLD PLACERVILLE RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95827-2539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-470-0071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 29TH ST STE 480
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-5173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-733-3777
Provider Business Practice Location Address Fax Number:
916-454-6780
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A93054 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: A93054 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131236 . This is a "HEALTH NET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1965271 . This is a "GREAT WEST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5662864 . This is a "FIRST HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: MCMG440900 . This is a "WESTERN HEALTH ADVANTAGE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 2671462 . This is a "UNITED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000810773563 . This is a "PHCS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 257707 . This is a "INTERPLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 7096720 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A93054 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0263265 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A930540 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A930540 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90201430 . This is a "PACIFICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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