Provider Demographics
NPI:1205862679
Name:BURLISON, KATHLEEN P (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:BURLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:P
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824
Mailing Address - Country:US
Mailing Address - Phone:203-259-7442
Mailing Address - Fax:203-259-5108
Practice Address - Street 1:111 BEACH RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-259-7442
Practice Address - Fax:203-259-5108
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39469Medicare UPIN
CT110008293Medicare ID - Type Unspecified