Provider Demographics
NPI:1821093972
Name:BURTLE, SALLY A (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:BURTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 NEVIN AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-3143
Mailing Address - Country:US
Mailing Address - Phone:510-307-2372
Mailing Address - Fax:510-307-2374
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3143
Practice Address - Country:US
Practice Address - Phone:510-307-2372
Practice Address - Fax:510-307-2374
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422621207N00000X
CAA94836207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3648861OtherAETNA
PA2224495000OtherKEYSTONE HP EAST
H95215Medicare UPIN
PA2224495000OtherKEYSTONE HP EAST