1891780565 NPI number — DR. LEANNE BURNETT M.D.

Table of content: DR. LEANNE BURNETT M.D. (NPI 1891780565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891780565 NPI number — DR. LEANNE BURNETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNETT
Provider First Name:
LEANNE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1891780565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2060 SPACE PARK DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77058-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-783-1999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2060 SPACE PARK DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77058-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-783-1999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2005

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: 2084N0400X , with the licence number:  H1934 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117383306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8GD877 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00106W . This is a "MNA MDCR GRP PTAN HARRIS CO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0035TD . This is a "BCBSTX GRP PROV REC #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 117383305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 153449704 . This is a "MNA MDCD GRP TPI HARRIS CO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8FG394 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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