Provider Demographics
NPI:1568634509
Name:BURK, BRANDON A (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:A
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:PO BOX 280
Mailing Address - Street 2:HOUSE STAFF OFFICE CP 21005
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-0280
Mailing Address - Country:US
Mailing Address - Phone:760-340-3911
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:39000 BOB HOPE DR DEPT OF
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-773-1251
Practice Address - Fax:800-409-7005
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1101732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1101730OtherBC/BS OF CA
CA1568634509Medicaid
CA00A1101730OtherBC/BS OF CA