Provider Demographics
NPI:1184841199
Name:BURGESS, JOSEPH WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WESLEY
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WES
Other - Middle Name:
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11980 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6604
Mailing Address - Country:US
Mailing Address - Phone:310-442-0177
Mailing Address - Fax:
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 620
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6604
Practice Address - Country:US
Practice Address - Phone:310-442-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG661832084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine