Provider Demographics
NPI:1558331181
Name:BURNETT, DEREK M (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DOWDELL
Other - Middle Name:C
Other - Last Name:DOWDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1791 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5648
Mailing Address - Country:US
Mailing Address - Phone:928-855-4248
Mailing Address - Fax:928-855-7452
Practice Address - Street 1:25 RIVIERA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5694
Practice Address - Country:US
Practice Address - Phone:928-505-5555
Practice Address - Fax:928-505-5557
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47110208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ915847Medicaid
G51159Medicare UPIN
AZZ168699Medicare PIN
AZZ168699Medicare PIN