Provider Demographics
NPI:1306820865
Name:BURNSIDES, DAVID D (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:BURNSIDES
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 1:5070 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3520
Mailing Address - Country:US
Mailing Address - Phone:614-764-1777
Mailing Address - Fax:614-764-9555
Practice Address - Street 1:5070 BRADENTON AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3520
Practice Address - Country:US
Practice Address - Phone:614-764-1777
Practice Address - Fax:614-764-9555
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-3547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0421529Medicaid
OH0500094Medicare PIN
OH0421529Medicaid