Provider Demographics
NPI:1013194281
Name:CURTIS D. BURGHART, OD, PS
Entity Type:Organization
Organization Name:CURTIS D. BURGHART, OD, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BURGHART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-736-4203
Mailing Address - Street 1:1203 S GOLD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-3715
Mailing Address - Country:US
Mailing Address - Phone:360-736-4203
Mailing Address - Fax:360-736-7059
Practice Address - Street 1:1203 S GOLD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3715
Practice Address - Country:US
Practice Address - Phone:360-736-4203
Practice Address - Fax:360-736-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013225Medicaid
WA2013225Medicaid
WAT12471Medicare UPIN
WAAB35380Medicare PIN