Provider Demographics
NPI:1801201496
Name:BURDICK, DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:BURDICK
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 1:2665 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1372
Mailing Address - Country:US
Mailing Address - Phone:801-842-9243
Mailing Address - Fax:
Practice Address - Street 1:2665 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1372
Practice Address - Country:US
Practice Address - Phone:801-842-9243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT156895-1205207P00000X
TXD4939207P00000X
CAC31759207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine