Provider Demographics
NPI:1821092198
Name:BURNETT, WILLIAM D (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:BURNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1003
Mailing Address - Country:US
Mailing Address - Phone:812-346-2020
Mailing Address - Fax:
Practice Address - Street 1:401 HENRY ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1003
Practice Address - Country:US
Practice Address - Phone:812-346-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001911B152W00000X
KY0928D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100194920Medicaid
IN000000087935OtherANTHEM
IN160660Medicare ID - Type Unspecified
IN100194920Medicaid
INT69278Medicare UPIN