Provider Demographics
NPI:1619954823
Name:BURGUN, CHANELE M (MD)
Entity Type:Individual
Prefix:
First Name:CHANELE
Middle Name:M
Last Name:BURGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HIGHBRIDGE ST C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1981
Mailing Address - Country:US
Mailing Address - Phone:315-637-0477
Mailing Address - Fax:315-637-0559
Practice Address - Street 1:212 HIGHBRIDGE ST C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1981
Practice Address - Country:US
Practice Address - Phone:315-637-0477
Practice Address - Fax:315-637-0559
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH84168Medicare UPIN