Provider Demographics
NPI:1134488281
Name:BURROUGHS, ADAM GLEN (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:GLEN
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 STANTON L YOUNG BLVD # WP3010
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5036
Mailing Address - Country:US
Mailing Address - Phone:405-271-4742
Mailing Address - Fax:405-271-2619
Practice Address - Street 1:4221 S WESTERN AVE STE 2010
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3445
Practice Address - Country:US
Practice Address - Phone:405-644-5120
Practice Address - Fax:405-644-5309
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10044544207R00000X
TXQ5769207R00000X
OK31974207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200654080AMedicaid