Provider Demographics
NPI:1235208638
Name:BURDENY, DEREK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALAN
Last Name:BURDENY
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:P.O. BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-3406
Practice Address - Street 1:2808 S 143RD PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5611
Practice Address - Country:US
Practice Address - Phone:402-609-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0C529212085R0202X
AZ400542085R0202X
CO467632085R0202X
IL036-1266842085R0202X
IA321832085R0202X
NVSP1732085R0202X
NJ25MA083773002085R0202X
NC95-008512085R0202X
OH35.0913312085R0202X
OK261162085R0202X
SD27772085R0202X
WA488952085R0202X
NE200552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052578200Medicaid
CA00C529210Medicaid
NJ0167266Medicaid
OK200215370Medicaid
NEP00457921OtherRAILROAD MEDICARE
NEP00457921OtherRAILROAD MEDICARE
CA00C529211Medicare UPIN
COCO303218Medicare PIN
CAAM679XMedicare PIN
NE47052578200Medicaid
CA00C529218Medicare PIN
CA00C529215Medicare PIN
NE274195Medicare PIN
CA00C529210Medicaid
CA00C529219Medicare PIN