Provider Demographics
NPI:1073520680
Name:BURNETT, DAVID BOYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BOYLE
Last Name:BURNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 24TH ST STE 315
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1891
Mailing Address - Country:US
Mailing Address - Phone:801-393-4413
Mailing Address - Fax:801-392-0376
Practice Address - Street 1:4848 S 900 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3726
Practice Address - Country:US
Practice Address - Phone:801-627-9868
Practice Address - Fax:801-627-9870
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56760929934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT56760929934OtherSTATE LICENSE
UT56760929934OtherSTATE LICENSE
UT56760929934OtherSTATE LICENSE
UT005801301Medicare ID - Type Unspecified
UTMB0719825OtherDEA