Provider Demographics
NPI:1114244068
Name:MAXFIELD, BURTON DERRIC (MD)
Entity Type:Individual
Prefix:DR
First Name:BURTON
Middle Name:DERRIC
Last Name:MAXFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B. DERRIC
Other - Middle Name:
Other - Last Name:MAXFIELD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2201 LINCOLN LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2826
Mailing Address - Country:US
Mailing Address - Phone:801-674-1239
Mailing Address - Fax:
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-634-4000
Practice Address - Fax:435-688-5673
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8140974-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000086637Medicare PIN