Provider Demographics
NPI:1366441438
Name:BURSE, LUTHER JR (MD)
Entity Type:Individual
Prefix:
First Name:LUTHER
Middle Name:
Last Name:BURSE
Suffix:JR
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 7865
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-0865
Mailing Address - Country:US
Mailing Address - Phone:404-881-8319
Mailing Address - Fax:404-523-6791
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:SUITE 1750
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-881-8319
Practice Address - Fax:404-523-6791
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043338174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00749713A*21Medicaid
GA00749713A*21Medicaid
GAG60347Medicare UPIN