Provider Demographics
NPI:1598712440
Name:BURGENER, RHETT MELVIN (OD)
Entity Type:Individual
Prefix:
First Name:RHETT
Middle Name:MELVIN
Last Name:BURGENER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 TALISMAN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8267
Mailing Address - Country:US
Mailing Address - Phone:928-505-5843
Mailing Address - Fax:928-854-9338
Practice Address - Street 1:1923 MCCULLOCH BLVD #102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6722
Practice Address - Country:US
Practice Address - Phone:928-854-3555
Practice Address - Fax:928-854-4544
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist