Provider Demographics
NPI:1467454918
Name:BURDETT, LAURENCE S (MD, PC)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:S
Last Name:BURDETT
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84402-0837
Mailing Address - Country:US
Mailing Address - Phone:801-392-0402
Mailing Address - Fax:801-393-3334
Practice Address - Street 1:3480 WASHINGTON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-4149
Practice Address - Country:US
Practice Address - Phone:801-392-0385
Practice Address - Fax:801-393-3334
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3404331205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G48944Medicare UPIN