Provider Demographics
NPI:1609437136
Name:BURSON, KELSEY J (DO)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:J
Last Name:BURSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 CARLSBAD VILLAGE DR APT 438
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1980
Mailing Address - Country:US
Mailing Address - Phone:916-214-0724
Mailing Address - Fax:
Practice Address - Street 1:1040 CARLSBAD VILLAGE DR APT 438
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1980
Practice Address - Country:US
Practice Address - Phone:916-214-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A20853207P00000X
MI1609437136207P00000X
MI5151013912390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program