Provider Demographics
NPI:1083468284
Name:BURKHARTZMEYER, BRIAN D (LIC C PED)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:BURKHARTZMEYER
Suffix:
Gender:M
Credentials:LIC C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CENTRAL AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:507-334-7774
Mailing Address - Fax:507-334-9256
Practice Address - Street 1:128 CENTRAL AVE NORTH
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-334-7774
Practice Address - Fax:507-334-9256
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist