Provider Demographics
NPI:1235236316
Name:BURNISTON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BURNISTON
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1020 29TH ST STE 480
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5173
Practice Address - Country:US
Practice Address - Phone:916-733-3777
Practice Address - Fax:916-454-6780
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93054207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA131236OtherHEALTH NET
CA1965271OtherGREAT WEST
CA5662864OtherFIRST HEALTH
CAMCMG440900OtherWESTERN HEALTH ADVANTAGE
CA2671462OtherUNITED
CA000810773563OtherPHCS
CA257707OtherINTERPLAN
CA7096720OtherAETNA
CAA93054OtherBLUE CROSS
CA0263265OtherCIGNA
CA00A930540OtherBLUE SHIELD
CA00A930540Medicaid
CA90201430OtherPACIFICARE
CA1965271OtherGREAT WEST
CA2671462OtherUNITED