Provider Demographics
NPI:1689680845
Name:BURGE, SCOTT DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:BURGE
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 1:800 PRINCE FREDERICK BLVD.
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678
Mailing Address - Country:US
Mailing Address - Phone:410-535-2270
Mailing Address - Fax:410-535-5749
Practice Address - Street 1:800 PRINCE FREDERICK BLVD.
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678
Practice Address - Country:US
Practice Address - Phone:410-535-2270
Practice Address - Fax:410-535-5749
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDA0778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT31207Medicare UPIN
MD751L697DMedicare PIN