Provider Demographics
NPI:1417271149
Name:BURDEX, CARL A
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:A
Last Name:BURDEX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 CRESTLINE CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-1321
Mailing Address - Country:US
Mailing Address - Phone:405-721-2687
Mailing Address - Fax:
Practice Address - Street 1:8220 CRESTLINE CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1321
Practice Address - Country:US
Practice Address - Phone:405-721-2687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid