Provider Demographics
NPI:1518028943
Name:BURGOYNE, KARL S (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:S
Last Name:BURGOYNE
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 1:1000 W CARSON ST
Mailing Address - Street 2:BOX 480
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-3135
Mailing Address - Fax:310-320-6973
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 8
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-3135
Practice Address - Fax:310-320-6973
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG678282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G678280Medicaid
CAWG67828FMedicare ID - Type UnspecifiedPPIN
CAE94616Medicare UPIN
CA00G678280Medicaid
CAWG67828GMedicare ID - Type UnspecifiedPPIN