Provider Demographics
NPI:1174630644
Name:BURK, ROBERT W III (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:BURK
Suffix:III
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 1:209 PONTE VEDRA PARK DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6600
Mailing Address - Country:US
Mailing Address - Phone:904-273-6200
Mailing Address - Fax:904-280-8013
Practice Address - Street 1:209 PONTE VEDRA PARK DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6600
Practice Address - Country:US
Practice Address - Phone:904-273-6200
Practice Address - Fax:904-280-8013
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57422174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377927100Medicaid
FL26758ZMedicare PIN
FLG02239Medicare UPIN