Provider Demographics
NPI:1518991033
Name:BURK, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:BURK
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 1:516 PEGRAM DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6347
Mailing Address - Country:US
Mailing Address - Phone:662-844-6272
Mailing Address - Fax:662-844-1603
Practice Address - Street 1:516 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6347
Practice Address - Country:US
Practice Address - Phone:662-844-6272
Practice Address - Fax:662-844-1603
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7919207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123008Medicaid
MSDOO800Medicare UPIN
MS00123008Medicaid