Provider Demographics
NPI:1255311247
Name:WARD, BURT WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:BURT
Middle Name:WILLIAM
Last Name:WARD
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 1:417A RACETRACK RD NW
Mailing Address - Street 2:STE 2
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4612
Mailing Address - Country:US
Mailing Address - Phone:850-863-5990
Mailing Address - Fax:850-862-0041
Practice Address - Street 1:417A RACETRACK RD NW
Practice Address - Street 2:STE 2
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4612
Practice Address - Country:US
Practice Address - Phone:850-863-5990
Practice Address - Fax:850-862-0041
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045373207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D54995Medicare UPIN
47180Medicare ID - Type Unspecified