Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | ME19766 | FL |
NPI | 1528040136 |
---|---|
Provider Name | Ronald Burk |
First Address | Rockledge, FL 32955-5401 |
Second Address | Rockledge, FL 32955-2138 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2005 |
Last Update Date | 25/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036995100 | (05) | FL |
D5874 | (02) | FL |