Provider Demographics
NPI:1003817024
Name:BURGHARDT, JOHN PETER JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PETER
Last Name:BURGHARDT
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1013 OLD TOWN RD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1853
Mailing Address - Country:US
Mailing Address - Phone:631-732-2590
Mailing Address - Fax:631-732-2590
Practice Address - Street 1:1013 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1853
Practice Address - Country:US
Practice Address - Phone:631-732-2590
Practice Address - Fax:631-732-2590
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002467213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT50768Medicare UPIN