Provider Demographics
NPI:1790795482
Name:BURKE, REGAN R (DO)
Entity Type:Individual
Prefix:DR
First Name:REGAN
Middle Name:R
Last Name:BURKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 N SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3330
Mailing Address - Country:US
Mailing Address - Phone:407-381-5381
Mailing Address - Fax:407-384-1143
Practice Address - Street 1:632 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3330
Practice Address - Country:US
Practice Address - Phone:407-381-5381
Practice Address - Fax:407-384-1143
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57155OtherBCBS
FLG31439Medicare UPIN
FL57155OtherBCBS