Provider Demographics
NPI:1790752681
Name:BURTMAN, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BURTMAN
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 1:294 CHUBBY DR
Mailing Address - Street 2:SUITE2
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1358
Mailing Address - Country:US
Mailing Address - Phone:662-327-2574
Mailing Address - Fax:662-327-2576
Practice Address - Street 1:294 CHUBBY LANE
Practice Address - Street 2:STE 2
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2016
Practice Address - Country:US
Practice Address - Phone:662-327-2574
Practice Address - Fax:662-327-2576
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07355897Medicaid
MSG86924Medicare UPIN
MS160000588Medicare ID - Type Unspecified