Provider Demographics
NPI:1679203681
Name:BURK, JUSTIN JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JAMES
Last Name:BURK
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 1:9035 S 1300 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3131
Mailing Address - Country:US
Mailing Address - Phone:801-566-4119
Mailing Address - Fax:
Practice Address - Street 1:9035 S 1300 E STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3131
Practice Address - Country:US
Practice Address - Phone:801-566-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12890769-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1841473295Medicaid