Provider Demographics
NPI:1508853946
Name:BURNETT, ROBERT ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:BURNETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 BROADWAY ST
Mailing Address - Street 2:STE 400
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7146
Mailing Address - Country:US
Mailing Address - Phone:270-444-7905
Mailing Address - Fax:270-444-7950
Practice Address - Street 1:2320 BROADWAY ST
Practice Address - Street 2:STE 400
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7146
Practice Address - Country:US
Practice Address - Phone:270-444-7905
Practice Address - Fax:270-444-7950
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00122213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYT54185Medicare UPIN
KY2005201Medicare UPIN