Provider Demographics
NPI:1386025492
Name:BURKETT, SAMUEL RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:RICHARD
Last Name:BURKETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GREENWICH DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-4454
Mailing Address - Country:US
Mailing Address - Phone:913-940-5485
Mailing Address - Fax:
Practice Address - Street 1:8 SOUTHWOODS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2554
Practice Address - Country:US
Practice Address - Phone:518-449-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008251152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management