Provider Demographics
NPI:1235393489
Name:BURDICK, BLAINE LANDON (OD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:LANDON
Last Name:BURDICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 4TH ST NE STE 1
Mailing Address - Street 2:P O BOX 888
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2479
Mailing Address - Country:US
Mailing Address - Phone:701-662-2817
Mailing Address - Fax:701-662-2040
Practice Address - Street 1:211 4TH ST NE STE 1
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2479
Practice Address - Country:US
Practice Address - Phone:701-662-2817
Practice Address - Fax:701-662-2040
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1235393489OtherND BLUE CROSS/SHIELD
ND60678Medicaid
ND893212OtherND VISION SERVICES
NDN714841Medicare PIN