Provider Demographics
NPI:1477817377
Name:BURNETT, TIMOTHY R (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:BURNETT
Suffix:
Gender:M
Credentials:DO
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 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2208
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1530 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6530
Practice Address - Country:US
Practice Address - Phone:417-269-1362
Practice Address - Fax:417-269-1372
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013027788207Q00000X
KS05-38110208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201113110AMedicaid
KS110116141Medicare PIN