Provider Demographics
NPI:1356631642
Name:BURTON, TINA MARIKO (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIKO
Last Name:BURTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:APC 747
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-606-8395
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC 747
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-606-8395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0430402084N0400X
RIMD157372084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology