Provider Demographics
NPI:1730112582
Name:VANDERBILT, BURTON LEE (MD)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:LEE
Last Name:VANDERBILT
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:3260 HOSPITAL DR
Mailing Address - Street 2:BURTONVANDERBILT MD PATHOLOGY DEPT. BARTLETT REG. HOSP.
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7808
Mailing Address - Country:US
Mailing Address - Phone:907-796-8841
Mailing Address - Fax:907-796-8494
Practice Address - Street 1:3260 HOSPITAL DR
Practice Address - Street 2:BURT VANDERBILT MD PATHOLOGY DEPT. BARTLETT REG. HOSP.
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7808
Practice Address - Country:US
Practice Address - Phone:907-796-8841
Practice Address - Fax:907-796-8494
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK4560207ZP0102X
WA17974207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4560Medicaid
AKE57831Medicare UPIN
AK8EC381Medicare ID - Type Unspecified