Provider Demographics
NPI:1205015229
Name:BURNETT, GERALD CRAIN (MD/)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:CRAIN
Last Name:BURNETT
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 1:405 OAK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1633
Mailing Address - Country:US
Mailing Address - Phone:434-572-6780
Mailing Address - Fax:434-572-6033
Practice Address - Street 1:405 OAK LN
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1633
Practice Address - Country:US
Practice Address - Phone:434-572-6780
Practice Address - Fax:434-572-6033
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101017885207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X583G01Medicare PIN
VAB06223Medicare UPIN
VA071888825Medicare PIN