Provider Demographics
NPI:1386677698
Name:BURNETT, ANTONIO CARLOS BERNAUD (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:CARLOS BERNAUD
Last Name:BURNETT
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 1:1675 E MAIN ST
Mailing Address - Street 2:BOX 328
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-5818
Mailing Address - Country:US
Mailing Address - Phone:330-593-1049
Mailing Address - Fax:330-572-3836
Practice Address - Street 1:1675 E MAIN ST
Practice Address - Street 2:BOX 328
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-5818
Practice Address - Country:US
Practice Address - Phone:330-593-1049
Practice Address - Fax:330-572-3836
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350921872085R0202X
FLME 656352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2873798Medicaid
E37343Medicare UPIN
OH2873798Medicaid
TXH4818OtherMEDICAL LICENSE
FLME6563OtherMEDICAL LICENSE
OH35.092187OtherMEDICAL LICENSE
OH2873798Medicaid
OH4245832Medicare PIN