Provider Demographics
NPI:1487652228
Name:BURRIS, RICHARD GERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GERALD
Last Name:BURRIS
Suffix:
Gender:M
Credentials:MD
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 728
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0728
Mailing Address - Country:US
Mailing Address - Phone:601-587-4648
Mailing Address - Fax:601-587-0613
Practice Address - Street 1:827 F E SELLERS HWY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-9378
Practice Address - Country:US
Practice Address - Phone:601-587-4648
Practice Address - Fax:601-587-0613
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015262Medicaid
D00650Medicare UPIN
MS00015262Medicaid