Provider Demographics
NPI:1407402506
Name:BURKEN, MITCHELL IRA (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:IRA
Last Name:BURKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MITCHELL
Other - Middle Name:IRA
Other - Last Name:BURKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5716 INDUSTRY LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-5224
Mailing Address - Country:US
Mailing Address - Phone:301-663-4130
Mailing Address - Fax:
Practice Address - Street 1:5716 INDUSTRY LN
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-5224
Practice Address - Country:US
Practice Address - Phone:301-663-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031869207RA0401X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine