Provider Demographics
NPI:1679648315
Name:BURDETTE, DAVID EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWIN
Last Name:BURDETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 6100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-267-7900
Practice Address - Fax:616-267-7901
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010567002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82659Medicare UPIN
130H264490OtherBLUE CROSS-BLUE CROSS
MI318852810Medicaid
DB056700OtherCHAMPUS-CHAMPUS
DB056700OtherCOMMERCIAL-COMMERCIAL NUMBER
MI3188528Medicaid
MIE82659Medicare UPIN