Provider Demographics
NPI:1750661328
Name:BURNAM, JESSE ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:ANDREW
Last Name:BURNAM
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 1:15647 CARRIEDALE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-3904
Mailing Address - Country:US
Mailing Address - Phone:239-768-3878
Mailing Address - Fax:239-768-3878
Practice Address - Street 1:15647 CARRIEDALE LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-3904
Practice Address - Country:US
Practice Address - Phone:239-768-3878
Practice Address - Fax:239-768-3878
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12233207YS0123X
NC13757207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery