Provider Demographics
NPI:1255473088
Name:BURSON, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:BURSON
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 2900
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-3535
Practice Address - Fax:417-820-3540
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204647010Medicaid
MO98570OtherAR BLUE SHIELD #
AR150465001Medicaid
MO199013268Medicare PIN
MO204647010Medicaid