Provider Demographics
NPI:1437142643
Name:BURCHETT, DWIGHT M (OD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:M
Last Name:BURCHETT
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 1:1020 GIBSON BAY DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3448
Mailing Address - Country:US
Mailing Address - Phone:859-623-3358
Mailing Address - Fax:859-623-8141
Practice Address - Street 1:1020 GIBSON BAY DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3448
Practice Address - Country:US
Practice Address - Phone:859-623-3358
Practice Address - Fax:859-623-8141
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1545 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7682422OtherAETNA
KY77000644Medicaid
KY432292OtherCIGNA
KY000000244922OtherANTHEM
KY000000244922OtherANTHEM
KY0958104Medicare PIN
KYMB0841305OtherDEA LICENSE
KY7682422OtherAETNA
KY432292OtherCIGNA
KY000000244922OtherANTHEM