Provider Demographics
NPI:1578869095
Name:BURKETT, ALLEN RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:RAY
Last Name:BURKETT
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 1:2274 SHADY GROVE LN
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1365
Mailing Address - Country:US
Mailing Address - Phone:734-850-2335
Mailing Address - Fax:
Practice Address - Street 1:2274 SHADY GROVE LN
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-1365
Practice Address - Country:US
Practice Address - Phone:734-850-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036813171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301036813OtherDEA BB4556912