Provider Demographics
NPI: | 1790738466 |
---|---|
Name: | BURNETT, CLAY M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CLAY |
Middle Name: | M |
Last Name: | BURNETT |
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: | 1824 KING ST |
Mailing Address - Street 2: | STE 200 |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32204 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-384-3343 |
Mailing Address - Fax: | 904-400-6671 |
Practice Address - Street 1: | 1824 KING ST |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32204 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-384-3343 |
Practice Address - Fax: | 904-400-6671 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-17 |
Last Update Date: | 2023-10-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01090546A | 208G00000X |
FL | ME122005 | 208G00000X |
KS | 0429960 | 208G00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1790738466 | Medicaid | |
KS | 100448810A | Medicaid | |
FL | HZ289Z | Medicare PIN | |
D60897 | Medicare UPIN | ||
KS | 100448810A | Medicaid |