Provider Demographics
NPI:1518962059
Name:BURTON, ERICA S (OD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:S
Last Name:BURTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GULF ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-1239
Mailing Address - Country:US
Mailing Address - Phone:417-682-3301
Mailing Address - Fax:417-682-2409
Practice Address - Street 1:808 GULF ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1239
Practice Address - Country:US
Practice Address - Phone:417-682-3301
Practice Address - Fax:417-682-2409
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03295152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118961OtherBC/BS
MO318614609Medicaid
MO318614609Medicaid
MO118961OtherBC/BS