Provider Demographics
NPI:1619347317
Name:BURGOS, ROBERT FITZGERALD (IDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:FITZGERALD
Last Name:BURGOS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2915
Mailing Address - Country:US
Mailing Address - Phone:956-533-2101
Mailing Address - Fax:
Practice Address - Street 1:SUBMARINE NAVAL BASE NEW LONDON
Practice Address - Street 2:BOX 159
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5159
Practice Address - Country:US
Practice Address - Phone:860-694-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279881671710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman