Provider Demographics
NPI:1487638706
Name:BURT, MELODY H (DO)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:H
Last Name:BURT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:315 E OLYMPIA AVE UNIT 223
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3823
Practice Address - Country:US
Practice Address - Phone:941-347-4588
Practice Address - Fax:941-205-2610
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS8961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71882OtherFL BC
FL71882OtherFL BC
FL71882ZMedicare PIN
FLG14202Medicare UPIN