Provider Demographics
NPI:1295839397
Name:BURLESON, STANLEY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:WAYNE
Last Name:BURLESON
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 352
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042
Mailing Address - Country:US
Mailing Address - Phone:870-946-1326
Mailing Address - Fax:870-946-4335
Practice Address - Street 1:705 W 16TH ST
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:AR
Practice Address - Zip Code:72042
Practice Address - Country:US
Practice Address - Phone:870-946-1326
Practice Address - Fax:870-946-4335
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
M038602OtherUNITED HEALTHCARE
AR102980001Medicaid
14220000000OtherPUAL CHOICE
M038602OtherUNITED HEALTHCARE