Provider Demographics
NPI:1629161864
Name:BURCHETT, KELLY DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DOUGLAS
Last Name:BURCHETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1605 SOUTH BALTIMORE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501
Mailing Address - Country:US
Mailing Address - Phone:660-665-3599
Mailing Address - Fax:660-665-3570
Practice Address - Street 1:1605 SOUTH BALTOMORE
Practice Address - Street 2:SUITE B
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-665-3599
Practice Address - Fax:660-665-3570
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010344207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207392200Medicaid
H52272Medicare UPIN
MO000014669Medicare ID - Type Unspecified