Provider Demographics
NPI:1477613420
Name:BURKS, DOUGLAS MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MATTHEW
Last Name:BURKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:BURKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1151 SHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-1601
Mailing Address - Country:US
Mailing Address - Phone:941-232-1000
Mailing Address - Fax:
Practice Address - Street 1:13055 SUMMERFIELD SQUARE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7402
Practice Address - Country:US
Practice Address - Phone:813-741-2473
Practice Address - Fax:813-672-6197
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045186207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01406YMedicare PIN
FL01406Medicare PIN
FL01406Medicare ID - Type Unspecified