Provider Demographics
NPI:1376713479
Name:BURKE, THERESA KIERNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:KIERNAN
Last Name:BURKE
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 1:14615 NW 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2844
Mailing Address - Country:US
Mailing Address - Phone:352-339-6464
Mailing Address - Fax:
Practice Address - Street 1:808 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3534
Practice Address - Country:US
Practice Address - Phone:352-339-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07615OtherBLUECROSSBLUESHIELD
FL07615OtherBLUECROSSBLUESHIELD
FLE21378Medicare UPIN