Provider Demographics
NPI:1225029507
Name:DR MARLON BURT OD PC
Entity Type:Organization
Organization Name:DR MARLON BURT OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-683-3888
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:KUTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19530-0268
Mailing Address - Country:US
Mailing Address - Phone:610-683-3888
Mailing Address - Fax:610-683-3083
Practice Address - Street 1:126 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-1712
Practice Address - Country:US
Practice Address - Phone:610-683-3888
Practice Address - Fax:610-683-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50041187OtherCAPITOL BLUE
PAMA1669529OtherBLUE SHIELD
3000375OtherKHPC
U79002Medicare UPIN
PA084751Medicare PIN
PA5354270001Medicare NSC
3000375OtherKHPC