Provider Demographics
NPI:1346208840
Name:BURLESON, GRADY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:L
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 1:228 YACHT CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6422
Mailing Address - Country:US
Mailing Address - Phone:904-521-2555
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91868207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL059187610OtherBCBS PROVIDER NUMBER
FL28769OtherBCBS PROVIDER NUMBER
AL059185325OtherBCBS PROVIDER NUMBER
FL273496600Medicaid
AL059185325OtherBCBS PROVIDER NUMBER
FL28769OtherBCBS PROVIDER NUMBER
FL28769BMedicare PIN
FLP00285628Medicare PIN
FL28769ZMedicare PIN